|
XR SPINE CERVICAL 2 OR 3 VIEWS
|
Facility
|
IP
|
$97.00
|
|
|
Service Code
|
CPT 72040 26
|
| Hospital Charge Code |
9727204001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$71.79 |
| Max. Negotiated Rate |
$92.15 |
| Rate for Payer: Aetna of VT Commercial |
$92.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$71.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$71.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$82.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$81.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$77.60
|
| Rate for Payer: Cash Price |
$48.50
|
| Rate for Payer: Cigna Commercial |
$77.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$77.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$77.60
|
| Rate for Payer: Multiplan Commercial |
$90.21
|
| Rate for Payer: MVP Health Care of NY Commercial |
$82.45
|
| Rate for Payer: United Healthcare Commercial |
$92.15
|
|
|
XR SPINE CERVICAL 2 OR 3 VIEWS
|
Facility
|
IP
|
$413.60
|
|
|
Service Code
|
CPT 72040
|
| Hospital Charge Code |
3207204001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$306.11 |
| Max. Negotiated Rate |
$392.92 |
| Rate for Payer: Aetna of VT Commercial |
$392.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$306.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$306.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$351.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$347.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$330.88
|
| Rate for Payer: Cash Price |
$206.80
|
| Rate for Payer: Cigna Commercial |
$330.88
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$330.88
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$330.88
|
| Rate for Payer: Multiplan Commercial |
$384.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$351.56
|
| Rate for Payer: United Healthcare Commercial |
$392.92
|
|
|
XR SPINE CERVICAL 4 OR 5 VIEWS
|
Facility
|
OP
|
$663.86
|
|
|
Service Code
|
CPT 72050
|
| Hospital Charge Code |
3207205001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$177.53 |
| Max. Negotiated Rate |
$630.67 |
| Rate for Payer: Aetna of VT Commercial |
$630.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$177.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$294.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$177.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$399.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$564.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$537.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$298.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$527.77
|
| Rate for Payer: Cash Price |
$331.93
|
| Rate for Payer: Cash Price |
$331.93
|
| Rate for Payer: Cigna Commercial |
$531.09
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$531.09
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$531.09
|
| Rate for Payer: Martins Point Health Care Commercial |
$298.74
|
| Rate for Payer: Multiplan Commercial |
$617.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$564.28
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$298.74
|
| Rate for Payer: United Healthcare Commercial |
$630.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$298.74
|
| Rate for Payer: United Healthcare VA CCN |
$298.74
|
|
|
XR SPINE CERVICAL 4 OR 5 VIEWS
|
Facility
|
IP
|
$252.00
|
|
|
Service Code
|
CPT 72050 26
|
| Hospital Charge Code |
9727205001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$186.51 |
| Max. Negotiated Rate |
$239.40 |
| Rate for Payer: Aetna of VT Commercial |
$239.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$186.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$186.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$214.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$211.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$201.60
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna Commercial |
$201.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$201.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$201.60
|
| Rate for Payer: Multiplan Commercial |
$234.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$214.20
|
| Rate for Payer: United Healthcare Commercial |
$239.40
|
|
|
XR SPINE CERVICAL 4 OR 5 VIEWS
|
Professional
|
Both
|
$252.00
|
|
|
Service Code
|
CPT 72050 26
|
| Hospital Charge Code |
9727205001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$12.43 |
| Max. Negotiated Rate |
$236.88 |
| Rate for Payer: Aetna of VT Commercial |
$236.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$177.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$12.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$177.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$17.40
|
| 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 |
$14.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$23.30
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna Commercial |
$18.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$12.44
|
| Rate for Payer: Multiplan Commercial |
$234.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.43
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$12.43
|
| Rate for Payer: United Healthcare Commercial |
$19.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.43
|
| Rate for Payer: United Healthcare VA CCN |
$12.43
|
|
|
XR SPINE CERVICAL 4 OR 5 VIEWS
|
Facility
|
OP
|
$252.00
|
|
|
Service Code
|
CPT 72050 26
|
| Hospital Charge Code |
9727205001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$111.61 |
| Max. Negotiated Rate |
$239.40 |
| Rate for Payer: Aetna of VT Commercial |
$239.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$225.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$111.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$225.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$151.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$214.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$204.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$113.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$200.34
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna Commercial |
$201.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$201.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$201.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$113.40
|
| Rate for Payer: Multiplan Commercial |
$234.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$214.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$113.40
|
| Rate for Payer: United Healthcare Commercial |
$239.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$113.40
|
| Rate for Payer: United Healthcare VA CCN |
$113.40
|
|
|
XR SPINE CERVICAL 4 OR 5 VIEWS
|
Facility
|
IP
|
$663.86
|
|
|
Service Code
|
CPT 72050
|
| Hospital Charge Code |
3207205001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$491.32 |
| Max. Negotiated Rate |
$630.67 |
| Rate for Payer: Aetna of VT Commercial |
$630.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$491.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$491.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$564.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$557.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$531.09
|
| Rate for Payer: Cash Price |
$331.93
|
| Rate for Payer: Cigna Commercial |
$531.09
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$531.09
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$531.09
|
| Rate for Payer: Multiplan Commercial |
$617.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$564.28
|
| Rate for Payer: United Healthcare Commercial |
$630.67
|
|
|
XR STERNOCLAVIC JT MIN 3 VIEWS
|
Facility
|
OP
|
$423.94
|
|
|
Service Code
|
CPT 71130
|
| Hospital Charge Code |
3207113001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$134.17 |
| Max. Negotiated Rate |
$402.74 |
| Rate for Payer: Aetna of VT Commercial |
$402.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$134.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$187.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$134.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$255.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$360.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$343.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$190.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$337.03
|
| Rate for Payer: Cash Price |
$211.97
|
| Rate for Payer: Cash Price |
$211.97
|
| Rate for Payer: Cigna Commercial |
$339.15
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$339.15
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$339.15
|
| Rate for Payer: Martins Point Health Care Commercial |
$190.77
|
| Rate for Payer: Multiplan Commercial |
$394.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$360.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$190.77
|
| Rate for Payer: United Healthcare Commercial |
$402.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$190.77
|
| Rate for Payer: United Healthcare VA CCN |
$190.77
|
|
|
XR STERNOCLAVIC JT MIN 3 VIEWS
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
CPT 71130 26
|
| Hospital Charge Code |
9727113001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$81.41 |
| Max. Negotiated Rate |
$104.50 |
| Rate for Payer: Aetna of VT Commercial |
$104.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$81.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$81.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$93.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$92.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$88.00
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cigna Commercial |
$88.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$88.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$88.00
|
| Rate for Payer: Multiplan Commercial |
$102.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$93.50
|
| Rate for Payer: United Healthcare Commercial |
$104.50
|
|
|
XR STERNOCLAVIC JT MIN 3 VIEWS
|
Facility
|
IP
|
$423.94
|
|
|
Service Code
|
CPT 71130
|
| Hospital Charge Code |
3207113001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$313.76 |
| Max. Negotiated Rate |
$402.74 |
| Rate for Payer: Aetna of VT Commercial |
$402.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$313.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$313.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$360.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$356.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$339.15
|
| Rate for Payer: Cash Price |
$211.97
|
| Rate for Payer: Cigna Commercial |
$339.15
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$339.15
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$339.15
|
| Rate for Payer: Multiplan Commercial |
$394.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$360.35
|
| Rate for Payer: United Healthcare Commercial |
$402.74
|
|
|
XR STERNOCLAVIC JT MIN 3 VIEWS
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
CPT 71130 26
|
| Hospital Charge Code |
9727113001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$48.72 |
| Max. Negotiated Rate |
$104.50 |
| Rate for Payer: Aetna of VT Commercial |
$104.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$98.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$48.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$98.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$66.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$93.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$89.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$49.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$87.45
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cigna Commercial |
$88.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$88.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$88.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$49.50
|
| Rate for Payer: Multiplan Commercial |
$102.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$93.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$49.50
|
| Rate for Payer: United Healthcare Commercial |
$104.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.50
|
| Rate for Payer: United Healthcare VA CCN |
$49.50
|
|
|
XR STERNOCLAVIC JT MIN 3 VIEWS
|
Professional
|
Both
|
$110.00
|
|
|
Service Code
|
CPT 71130 26
|
| Hospital Charge Code |
9727113001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$9.85 |
| Max. Negotiated Rate |
$134.17 |
| Rate for Payer: Aetna of VT Commercial |
$103.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$134.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$10.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$134.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$13.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$16.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$16.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$11.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$16.56
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cigna Commercial |
$14.97
|
| Rate for Payer: Martins Point Health Care Commercial |
$9.86
|
| Rate for Payer: Multiplan Commercial |
$102.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$9.85
|
| Rate for Payer: United Healthcare Commercial |
$15.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.85
|
| Rate for Payer: United Healthcare VA CCN |
$9.85
|
|
|
XR STERNUM MIN 2 VIEWS
|
Facility
|
IP
|
$431.18
|
|
|
Service Code
|
CPT 71120
|
| Hospital Charge Code |
3207112001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$319.12 |
| Max. Negotiated Rate |
$409.62 |
| Rate for Payer: Aetna of VT Commercial |
$409.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$319.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$319.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$366.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$362.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$344.94
|
| Rate for Payer: Cash Price |
$215.59
|
| Rate for Payer: Cigna Commercial |
$344.94
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$344.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$344.94
|
| Rate for Payer: Multiplan Commercial |
$401.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$366.50
|
| Rate for Payer: United Healthcare Commercial |
$409.62
|
|
|
XR STERNUM MIN 2 VIEWS
|
Facility
|
OP
|
$431.18
|
|
|
Service Code
|
CPT 71120
|
| Hospital Charge Code |
3207112001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$105.28 |
| Max. Negotiated Rate |
$409.62 |
| Rate for Payer: Aetna of VT Commercial |
$409.62
|
| 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 |
$190.97
|
| 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 |
$259.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$366.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$349.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$194.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$342.79
|
| Rate for Payer: Cash Price |
$215.59
|
| Rate for Payer: Cash Price |
$215.59
|
| Rate for Payer: Cigna Commercial |
$344.94
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$344.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$344.94
|
| Rate for Payer: Martins Point Health Care Commercial |
$194.03
|
| Rate for Payer: Multiplan Commercial |
$401.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$366.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$194.03
|
| Rate for Payer: United Healthcare Commercial |
$409.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$194.03
|
| Rate for Payer: United Healthcare VA CCN |
$194.03
|
|
|
XR STERNUM MIN 2 VIEWS
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
CPT 71120 26
|
| Hospital Charge Code |
9727112001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$39.42 |
| Max. Negotiated Rate |
$84.55 |
| Rate for Payer: Aetna of VT Commercial |
$84.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$79.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$39.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$79.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$53.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$75.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$72.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$40.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$70.75
|
| Rate for Payer: Cash Price |
$44.50
|
| Rate for Payer: Cigna Commercial |
$71.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$71.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$71.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$40.05
|
| Rate for Payer: Multiplan Commercial |
$82.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$75.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$40.05
|
| Rate for Payer: United Healthcare Commercial |
$84.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$40.05
|
| Rate for Payer: United Healthcare VA CCN |
$40.05
|
|
|
XR STERNUM MIN 2 VIEWS
|
Professional
|
Both
|
$89.00
|
|
|
Service Code
|
CPT 71120 26
|
| Hospital Charge Code |
9727112001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$8.89 |
| Max. Negotiated Rate |
$105.28 |
| Rate for Payer: Aetna of VT Commercial |
$83.66
|
| 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 |
$9.16
|
| 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 |
$12.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$15.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$15.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$10.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$15.50
|
| Rate for Payer: Cash Price |
$44.50
|
| Rate for Payer: Cash Price |
$44.50
|
| Rate for Payer: Cigna Commercial |
$13.50
|
| Rate for Payer: Martins Point Health Care Commercial |
$8.89
|
| Rate for Payer: Multiplan Commercial |
$82.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$8.89
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$8.89
|
| Rate for Payer: United Healthcare Commercial |
$13.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.89
|
| Rate for Payer: United Healthcare VA CCN |
$8.89
|
|
|
XR STERNUM MIN 2 VIEWS
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
CPT 71120 26
|
| Hospital Charge Code |
9727112001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$65.87 |
| Max. Negotiated Rate |
$84.55 |
| Rate for Payer: Aetna of VT Commercial |
$84.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$65.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$65.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$75.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$74.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$71.20
|
| Rate for Payer: Cash Price |
$44.50
|
| Rate for Payer: Cigna Commercial |
$71.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$71.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$71.20
|
| Rate for Payer: Multiplan Commercial |
$82.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$75.65
|
| Rate for Payer: United Healthcare Commercial |
$84.55
|
|
|
XR THORACIC 3 VIEWS
|
Professional
|
Both
|
$110.00
|
|
|
Service Code
|
CPT 72072 26
|
| Hospital Charge Code |
9727207201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$10.18 |
| Max. Negotiated Rate |
$125.51 |
| Rate for Payer: Aetna of VT Commercial |
$103.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$125.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$10.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$125.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$14.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$16.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$16.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$11.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$16.56
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cigna Commercial |
$15.46
|
| Rate for Payer: Martins Point Health Care Commercial |
$10.18
|
| Rate for Payer: Multiplan Commercial |
$102.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.18
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$10.18
|
| Rate for Payer: United Healthcare Commercial |
$15.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.18
|
| Rate for Payer: United Healthcare VA CCN |
$10.18
|
|
|
XR THORACIC 3 VIEWS
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
CPT 72072 26
|
| Hospital Charge Code |
9727207201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$48.72 |
| Max. Negotiated Rate |
$104.50 |
| Rate for Payer: Aetna of VT Commercial |
$104.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$98.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$48.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$98.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$66.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$93.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$89.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$49.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$87.45
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cigna Commercial |
$88.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$88.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$88.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$49.50
|
| Rate for Payer: Multiplan Commercial |
$102.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$93.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$49.50
|
| Rate for Payer: United Healthcare Commercial |
$104.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.50
|
| Rate for Payer: United Healthcare VA CCN |
$49.50
|
|
|
XR THORACIC 3 VIEWS
|
Facility
|
IP
|
$621.43
|
|
|
Service Code
|
CPT 72072
|
| Hospital Charge Code |
3207207201
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$459.92 |
| Max. Negotiated Rate |
$590.36 |
| Rate for Payer: Aetna of VT Commercial |
$590.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$459.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$459.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$528.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$522.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$497.14
|
| Rate for Payer: Cash Price |
$310.71
|
| Rate for Payer: Cigna Commercial |
$497.14
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$497.14
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$497.14
|
| Rate for Payer: Multiplan Commercial |
$577.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$528.22
|
| Rate for Payer: United Healthcare Commercial |
$590.36
|
|
|
XR THORACIC 3 VIEWS
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
CPT 72072 26
|
| Hospital Charge Code |
9727207201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$81.41 |
| Max. Negotiated Rate |
$104.50 |
| Rate for Payer: Aetna of VT Commercial |
$104.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$81.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$81.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$93.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$92.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$88.00
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cigna Commercial |
$88.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$88.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$88.00
|
| Rate for Payer: Multiplan Commercial |
$102.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$93.50
|
| Rate for Payer: United Healthcare Commercial |
$104.50
|
|
|
XR THORACIC 3 VIEWS
|
Facility
|
OP
|
$621.43
|
|
|
Service Code
|
CPT 72072
|
| Hospital Charge Code |
3207207201
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$125.51 |
| Max. Negotiated Rate |
$590.36 |
| Rate for Payer: Aetna of VT Commercial |
$590.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$125.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$275.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$125.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$374.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$528.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$503.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$279.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$494.04
|
| Rate for Payer: Cash Price |
$310.71
|
| Rate for Payer: Cash Price |
$310.71
|
| Rate for Payer: Cigna Commercial |
$497.14
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$497.14
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$497.14
|
| Rate for Payer: Martins Point Health Care Commercial |
$279.64
|
| Rate for Payer: Multiplan Commercial |
$577.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$528.22
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$279.64
|
| Rate for Payer: United Healthcare Commercial |
$590.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$279.64
|
| Rate for Payer: United Healthcare VA CCN |
$279.64
|
|
|
XR THORACIC MIN 4 VIEWS
|
Facility
|
OP
|
$646.77
|
|
|
Service Code
|
CPT 72074
|
| Hospital Charge Code |
3207207401
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$142.83 |
| Max. Negotiated Rate |
$614.43 |
| Rate for Payer: Aetna of VT Commercial |
$614.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$142.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$286.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$142.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$389.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$549.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$523.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$291.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$514.18
|
| Rate for Payer: Cash Price |
$323.38
|
| Rate for Payer: Cash Price |
$323.38
|
| Rate for Payer: Cigna Commercial |
$517.42
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$517.42
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$517.42
|
| Rate for Payer: Martins Point Health Care Commercial |
$291.05
|
| Rate for Payer: Multiplan Commercial |
$601.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$549.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$291.05
|
| Rate for Payer: United Healthcare Commercial |
$614.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$291.05
|
| Rate for Payer: United Healthcare VA CCN |
$291.05
|
|
|
XR THORACIC MIN 4 VIEWS
|
Facility
|
OP
|
$133.00
|
|
|
Service Code
|
CPT 72074 26
|
| Hospital Charge Code |
9727207401
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$58.91 |
| Max. Negotiated Rate |
$126.35 |
| Rate for Payer: Aetna of VT Commercial |
$126.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$119.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$58.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$119.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$80.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$113.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$107.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$59.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$105.73
|
| Rate for Payer: Cash Price |
$66.50
|
| Rate for Payer: Cigna Commercial |
$106.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$106.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$106.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$59.85
|
| Rate for Payer: Multiplan Commercial |
$123.69
|
| Rate for Payer: MVP Health Care of NY Commercial |
$113.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$59.85
|
| Rate for Payer: United Healthcare Commercial |
$126.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$59.85
|
| Rate for Payer: United Healthcare VA CCN |
$59.85
|
|
|
XR THORACIC MIN 4 VIEWS
|
Facility
|
IP
|
$133.00
|
|
|
Service Code
|
CPT 72074 26
|
| Hospital Charge Code |
9727207401
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$98.43 |
| Max. Negotiated Rate |
$126.35 |
| Rate for Payer: Aetna of VT Commercial |
$126.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$98.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$98.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$113.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$111.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$106.40
|
| Rate for Payer: Cash Price |
$66.50
|
| Rate for Payer: Cigna Commercial |
$106.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$106.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$106.40
|
| Rate for Payer: Multiplan Commercial |
$123.69
|
| Rate for Payer: MVP Health Care of NY Commercial |
$113.05
|
| Rate for Payer: United Healthcare Commercial |
$126.35
|
|
