|
SARS-COV-2 COVID19 W/OPTIC
|
Facility
|
OP
|
$289.27
|
|
|
Service Code
|
CPT 87811
|
| Hospital Charge Code |
3008781101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$41.38 |
| Max. Negotiated Rate |
$274.81 |
| Rate for Payer: Aetna of VT Commercial |
$274.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$203.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$128.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$203.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$174.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$245.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$234.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$130.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$229.97
|
| Rate for Payer: Cash Price |
$144.64
|
| Rate for Payer: Cash Price |
$144.64
|
| Rate for Payer: Cigna Commercial |
$231.42
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$231.42
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$231.42
|
| Rate for Payer: Martins Point Health Care Commercial |
$130.17
|
| Rate for Payer: Multiplan Commercial |
$269.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$245.88
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$130.17
|
| Rate for Payer: United Healthcare Commercial |
$274.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$41.38
|
| Rate for Payer: United Healthcare VA CCN |
$130.17
|
|
|
SARSCOV2 & INF A&B AMP PRB
|
Facility
|
IP
|
$1,076.00
|
|
|
Service Code
|
CPT 87636
|
| Hospital Charge Code |
3008763601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$796.35 |
| Max. Negotiated Rate |
$1,022.20 |
| Rate for Payer: Aetna of VT Commercial |
$1,022.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$796.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$796.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$914.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$903.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$860.80
|
| Rate for Payer: Cash Price |
$538.00
|
| Rate for Payer: Cigna Commercial |
$860.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$860.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$860.80
|
| Rate for Payer: Multiplan Commercial |
$1,000.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$914.60
|
| Rate for Payer: United Healthcare Commercial |
$1,022.20
|
|
|
SARSCOV2 & INF A&B AMP PRB
|
Facility
|
OP
|
$1,076.00
|
|
|
Service Code
|
CPT 87636
|
| Hospital Charge Code |
3008763601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$142.63 |
| Max. Negotiated Rate |
$1,022.20 |
| Rate for Payer: Aetna of VT Commercial |
$1,022.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$702.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$476.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$702.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$647.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$914.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$871.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$484.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$855.42
|
| Rate for Payer: Cash Price |
$538.00
|
| Rate for Payer: Cash Price |
$538.00
|
| Rate for Payer: Cigna Commercial |
$860.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$860.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$860.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$484.20
|
| Rate for Payer: Multiplan Commercial |
$1,000.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$914.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$484.20
|
| Rate for Payer: United Healthcare Commercial |
$1,022.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$142.63
|
| Rate for Payer: United Healthcare VA CCN |
$484.20
|
|
|
SARSCOV2&INF A&B&RSV AMP PRB
|
Facility
|
OP
|
$401.00
|
|
|
Service Code
|
CPT 87637
|
| Hospital Charge Code |
3008763701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$142.63 |
| Max. Negotiated Rate |
$702.81 |
| Rate for Payer: Aetna of VT Commercial |
$380.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$702.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$177.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$702.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$241.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$340.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$324.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$180.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$318.80
|
| Rate for Payer: Cash Price |
$200.50
|
| Rate for Payer: Cash Price |
$200.50
|
| Rate for Payer: Cigna Commercial |
$320.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$320.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$320.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$180.45
|
| Rate for Payer: Multiplan Commercial |
$372.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$340.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$180.45
|
| Rate for Payer: United Healthcare Commercial |
$380.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$142.63
|
| Rate for Payer: United Healthcare VA CCN |
$180.45
|
|
|
SARSCOV2&INF A&B&RSV AMP PRB
|
Facility
|
IP
|
$401.00
|
|
|
Service Code
|
CPT 87637
|
| Hospital Charge Code |
3008763701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$296.78 |
| Max. Negotiated Rate |
$380.95 |
| Rate for Payer: Aetna of VT Commercial |
$380.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$296.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$296.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$340.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$336.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$320.80
|
| Rate for Payer: Cash Price |
$200.50
|
| Rate for Payer: Cigna Commercial |
$320.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$320.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$320.80
|
| Rate for Payer: Multiplan Commercial |
$372.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$340.85
|
| Rate for Payer: United Healthcare Commercial |
$380.95
|
|
|
SARSCOV2 VAC 100MCG/0.5ML IM
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 91301
|
| Hospital Charge Code |
6369130101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
SARSCOV2 VAC 100MCG/0.5ML IM
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 91301
|
| Hospital Charge Code |
6369130101
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
SARSCOV2 VAC 100MCG/0.5ML IM
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 91301
|
| Hospital Charge Code |
6369130101
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
SARSCOV2 VAC 30MCG/0.3ML IM
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 91300
|
| Hospital Charge Code |
6369130001
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
SARSCOV2 VAC 30MCG/0.3ML IM
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 91300
|
| Hospital Charge Code |
6369130001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
SARSCOV2 VAC 30MCG/0.3ML IM
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 91300
|
| Hospital Charge Code |
6369130001
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
SARSCOV2 VAC 50MCG/0.25ML IM
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 91306
|
| Hospital Charge Code |
6369130601
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
SARSCOV2 VAC 50MCG/0.25ML IM
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 91306
|
| Hospital Charge Code |
6369130601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
SARSCOV2 VAC 50MCG/0.25ML IM
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 91306
|
| Hospital Charge Code |
6369130601
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
SARSCOV CORONAVIRUS AG IA
|
Facility
|
IP
|
$92.59
|
|
|
Service Code
|
CPT 87426
|
| Hospital Charge Code |
3008742601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$68.53 |
| Max. Negotiated Rate |
$87.96 |
| Rate for Payer: Aetna of VT Commercial |
$87.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$68.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$68.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$78.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$77.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$74.07
|
| Rate for Payer: Cash Price |
$46.30
|
| Rate for Payer: Cigna Commercial |
$74.07
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$74.07
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$74.07
|
| Rate for Payer: Multiplan Commercial |
$86.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$78.70
|
| Rate for Payer: United Healthcare Commercial |
$87.96
|
|
|
SARSCOV CORONAVIRUS AG IA
|
Facility
|
OP
|
$92.59
|
|
|
Service Code
|
CPT 87426
|
| Hospital Charge Code |
3008742601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.33 |
| Max. Negotiated Rate |
$174.09 |
| Rate for Payer: Aetna of VT Commercial |
$87.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$174.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$41.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$174.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$55.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$78.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$75.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$41.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$73.61
|
| Rate for Payer: Cash Price |
$46.30
|
| Rate for Payer: Cash Price |
$46.30
|
| Rate for Payer: Cigna Commercial |
$74.07
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$74.07
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$74.07
|
| Rate for Payer: Martins Point Health Care Commercial |
$41.67
|
| Rate for Payer: Multiplan Commercial |
$86.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$78.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$41.67
|
| Rate for Payer: United Healthcare Commercial |
$87.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.33
|
| Rate for Payer: United Healthcare VA CCN |
$41.67
|
|
|
SARSCOV & INF VIR A&B AG IA
|
Facility
|
OP
|
$238.00
|
|
|
Service Code
|
CPT 87428
|
| Hospital Charge Code |
3008742801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$70.29 |
| Max. Negotiated Rate |
$346.35 |
| Rate for Payer: Aetna of VT Commercial |
$226.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$346.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$105.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$346.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$143.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$202.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$192.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$107.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$189.21
|
| Rate for Payer: Cash Price |
$119.00
|
| Rate for Payer: Cash Price |
$119.00
|
| Rate for Payer: Cigna Commercial |
$190.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$190.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$190.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$107.10
|
| Rate for Payer: Multiplan Commercial |
$221.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$202.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$107.10
|
| Rate for Payer: United Healthcare Commercial |
$226.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$70.29
|
| Rate for Payer: United Healthcare VA CCN |
$107.10
|
|
|
SARSCOV & INF VIR A&B AG IA
|
Facility
|
IP
|
$238.00
|
|
|
Service Code
|
CPT 87428
|
| Hospital Charge Code |
3008742801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$176.14 |
| Max. Negotiated Rate |
$226.10 |
| Rate for Payer: Aetna of VT Commercial |
$226.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$176.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$176.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$202.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$199.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$190.40
|
| Rate for Payer: Cash Price |
$119.00
|
| Rate for Payer: Cigna Commercial |
$190.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$190.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$190.40
|
| Rate for Payer: Multiplan Commercial |
$221.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$202.30
|
| Rate for Payer: United Healthcare Commercial |
$226.10
|
|
|
SARSCV2 VAC 30MCG 12 yrs old >
|
Facility
|
IP
|
$135.74
|
|
|
Service Code
|
CPT 91320
|
| Hospital Charge Code |
6369132001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.46 |
| Max. Negotiated Rate |
$128.95 |
| Rate for Payer: Aetna of VT Commercial |
$128.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$100.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$100.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$115.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$114.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$108.59
|
| Rate for Payer: Cash Price |
$67.87
|
| Rate for Payer: Cigna Commercial |
$108.59
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$108.59
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$108.59
|
| Rate for Payer: Multiplan Commercial |
$126.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$115.38
|
| Rate for Payer: United Healthcare Commercial |
$128.95
|
|
|
SARSCV2 VAC 30MCG 12 yrs old >
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 91320
|
| Hospital Charge Code |
6369132001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$428.73 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$428.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$173.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$428.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$235.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$155.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$155.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$193.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$155.90
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$216.53
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$216.53
|
| Rate for Payer: Martins Point Health Care Commercial |
$155.90
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$168.37
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$168.37
|
| Rate for Payer: United Healthcare Commercial |
$259.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$168.37
|
| Rate for Payer: United Healthcare VA CCN |
$168.37
|
|
|
SARSCV2 VAC 30MCG 12 yrs old >
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
HCPCS 91320
|
| Hospital Charge Code |
6369132001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$428.73 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$428.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$173.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$428.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$235.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$155.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$155.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$193.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$155.90
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$216.53
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$216.53
|
| Rate for Payer: Martins Point Health Care Commercial |
$155.90
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$168.37
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$168.37
|
| Rate for Payer: United Healthcare Commercial |
$259.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$168.37
|
| Rate for Payer: United Healthcare VA CCN |
$168.37
|
|
|
SARSCV2 VAC 30MCG 12 yrs old >
|
Facility
|
OP
|
$135.74
|
|
|
Service Code
|
CPT 91320
|
| Hospital Charge Code |
6369132001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.12 |
| Max. Negotiated Rate |
$428.73 |
| Rate for Payer: Aetna of VT Commercial |
$128.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$428.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$60.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$428.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$81.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$115.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$109.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$61.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$107.91
|
| Rate for Payer: Cash Price |
$67.87
|
| Rate for Payer: Cash Price |
$67.87
|
| Rate for Payer: Cigna Commercial |
$108.59
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$108.59
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$108.59
|
| Rate for Payer: Martins Point Health Care Commercial |
$61.08
|
| Rate for Payer: Multiplan Commercial |
$126.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$115.38
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$61.08
|
| Rate for Payer: United Healthcare Commercial |
$128.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$61.08
|
| Rate for Payer: United Healthcare VA CCN |
$61.08
|
|
|
SARSCV2 VAC 30MCG 12 yrs old >
|
Facility
|
IP
|
$135.74
|
|
|
Service Code
|
HCPCS 91320
|
| Hospital Charge Code |
6369132001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.46 |
| Max. Negotiated Rate |
$128.95 |
| Rate for Payer: Aetna of VT Commercial |
$128.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$100.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$100.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$115.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$114.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$108.59
|
| Rate for Payer: Cash Price |
$67.87
|
| Rate for Payer: Cigna Commercial |
$108.59
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$108.59
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$108.59
|
| Rate for Payer: Multiplan Commercial |
$126.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$115.38
|
| Rate for Payer: United Healthcare Commercial |
$128.95
|
|
|
SARSCV2 VAC 30MCG 12 yrs old >
|
Facility
|
OP
|
$135.74
|
|
|
Service Code
|
HCPCS 91320
|
| Hospital Charge Code |
6369132001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.12 |
| Max. Negotiated Rate |
$428.73 |
| Rate for Payer: Aetna of VT Commercial |
$128.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$428.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$60.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$428.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$81.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$115.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$109.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$61.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$107.91
|
| Rate for Payer: Cash Price |
$67.87
|
| Rate for Payer: Cash Price |
$67.87
|
| Rate for Payer: Cigna Commercial |
$108.59
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$108.59
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$108.59
|
| Rate for Payer: Martins Point Health Care Commercial |
$61.08
|
| Rate for Payer: Multiplan Commercial |
$126.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$115.38
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$61.08
|
| Rate for Payer: United Healthcare Commercial |
$128.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$61.08
|
| Rate for Payer: United Healthcare VA CCN |
$61.08
|
|
|
SARSCV2 VAC 30MCG TRS > 65 YO
|
Facility
|
IP
|
$412.03
|
|
|
Service Code
|
CPT 91320
|
| Hospital Charge Code |
6369132002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$304.94 |
| Max. Negotiated Rate |
$391.43 |
| Rate for Payer: Aetna of VT Commercial |
$391.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$304.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$304.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$350.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$346.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$329.62
|
| Rate for Payer: Cash Price |
$206.01
|
| Rate for Payer: Cigna Commercial |
$329.62
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$329.62
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$329.62
|
| Rate for Payer: Multiplan Commercial |
$383.19
|
| Rate for Payer: MVP Health Care of NY Commercial |
$350.23
|
| Rate for Payer: United Healthcare Commercial |
$391.43
|
|
