|
SARSCV2 VAC 30MCG TRS > 65 YO
|
Professional
|
Both
|
$412.03
|
|
|
Service Code
|
CPT 91320
|
| Hospital Charge Code |
6369132002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.90 |
| Max. Negotiated Rate |
$428.73 |
| Rate for Payer: Aetna of VT Commercial |
$387.31
|
| 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: Cash Price |
$206.01
|
| Rate for Payer: Cash Price |
$206.01
|
| 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 |
$383.19
|
| 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 TRS > 65 YO
|
Facility
|
OP
|
$412.03
|
|
|
Service Code
|
CPT 91320
|
| Hospital Charge Code |
6369132002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$182.49 |
| Max. Negotiated Rate |
$428.73 |
| Rate for Payer: Aetna of VT Commercial |
$391.43
|
| 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 |
$182.49
|
| 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 |
$248.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$350.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$333.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$185.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$327.56
|
| Rate for Payer: Cash Price |
$206.01
|
| 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: Martins Point Health Care Commercial |
$185.41
|
| Rate for Payer: Multiplan Commercial |
$383.19
|
| Rate for Payer: MVP Health Care of NY Commercial |
$350.23
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$185.41
|
| Rate for Payer: United Healthcare Commercial |
$391.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$185.41
|
| Rate for Payer: United Healthcare VA CCN |
$185.41
|
|
|
SARSCV2 VAC 30MCG TRS-SUC SYR
|
Facility
|
OP
|
$135.74
|
|
|
Service Code
|
CPT 91320
|
| Hospital Charge Code |
6369132003
|
|
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-SUC SYR
|
Facility
|
IP
|
$135.74
|
|
|
Service Code
|
CPT 91320
|
| Hospital Charge Code |
6369132003
|
|
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
|
|
|
SBSQ HOSPITAL CARE 15 MIN
|
Facility
|
IP
|
$139.00
|
|
|
Service Code
|
CPT 99231
|
| Hospital Charge Code |
9879923101
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$102.87 |
| Max. Negotiated Rate |
$132.05 |
| Rate for Payer: Aetna of VT Commercial |
$132.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$102.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$102.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$118.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$116.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$111.20
|
| Rate for Payer: Cash Price |
$69.50
|
| Rate for Payer: Cigna Commercial |
$111.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$111.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$111.20
|
| Rate for Payer: Multiplan Commercial |
$129.27
|
| Rate for Payer: MVP Health Care of NY Commercial |
$118.15
|
| Rate for Payer: United Healthcare Commercial |
$132.05
|
|
|
SBSQ HOSPITAL CARE 15 MIN
|
Professional
|
Both
|
$139.00
|
|
|
Service Code
|
CPT 99231
|
| Hospital Charge Code |
9879923101
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$45.89 |
| Max. Negotiated Rate |
$130.66 |
| Rate for Payer: Aetna of VT Commercial |
$130.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$59.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$47.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$59.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$64.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$62.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$62.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$52.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$62.52
|
| Rate for Payer: Cash Price |
$69.50
|
| Rate for Payer: Cash Price |
$69.50
|
| Rate for Payer: Cigna Commercial |
$50.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$75.08
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$75.08
|
| Rate for Payer: Martins Point Health Care Commercial |
$45.90
|
| Rate for Payer: Multiplan Commercial |
$129.27
|
| Rate for Payer: MVP Health Care of NY Commercial |
$65.16
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$45.89
|
| Rate for Payer: United Healthcare Commercial |
$70.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$45.89
|
| Rate for Payer: United Healthcare VA CCN |
$45.89
|
|
|
SBSQ HOSPITAL CARE 15 MIN
|
Facility
|
OP
|
$139.00
|
|
|
Service Code
|
CPT 99231
|
| Hospital Charge Code |
9879923101
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$61.56 |
| Max. Negotiated Rate |
$132.05 |
| Rate for Payer: Aetna of VT Commercial |
$132.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$124.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$61.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$124.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$83.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$118.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$112.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$62.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$110.50
|
| Rate for Payer: Cash Price |
$69.50
|
| Rate for Payer: Cigna Commercial |
$111.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$111.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$111.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$62.55
|
| Rate for Payer: Multiplan Commercial |
$129.27
|
| Rate for Payer: MVP Health Care of NY Commercial |
$118.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$62.55
|
| Rate for Payer: United Healthcare Commercial |
$132.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.55
|
| Rate for Payer: United Healthcare VA CCN |
$62.55
|
|
|
SBSQ HOSPITAL CARE 25 MIN
|
Facility
|
OP
|
$203.00
|
|
|
Service Code
|
CPT 99232
|
| Hospital Charge Code |
9879923201
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$89.91 |
| Max. Negotiated Rate |
$192.85 |
| Rate for Payer: Aetna of VT Commercial |
$192.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$181.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$89.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$181.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$122.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$172.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$164.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$91.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$161.38
|
| Rate for Payer: Cash Price |
$101.50
|
| Rate for Payer: Cigna Commercial |
$162.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$162.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$162.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$91.35
|
| Rate for Payer: Multiplan Commercial |
$188.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$172.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$91.35
|
| Rate for Payer: United Healthcare Commercial |
$192.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.35
|
| Rate for Payer: United Healthcare VA CCN |
$91.35
|
|
|
SBSQ HOSPITAL CARE 25 MIN
|
Facility
|
IP
|
$203.00
|
|
|
Service Code
|
CPT 99232
|
| Hospital Charge Code |
9879923201
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$150.24 |
| Max. Negotiated Rate |
$192.85 |
| Rate for Payer: Aetna of VT Commercial |
$192.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$150.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$150.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$172.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$170.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$162.40
|
| Rate for Payer: Cash Price |
$101.50
|
| Rate for Payer: Cigna Commercial |
$162.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$162.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$162.40
|
| Rate for Payer: Multiplan Commercial |
$188.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$172.55
|
| Rate for Payer: United Healthcare Commercial |
$192.85
|
|
|
SBSQ HOSPITAL CARE 25 MIN
|
Professional
|
Both
|
$203.00
|
|
|
Service Code
|
CPT 99232
|
| Hospital Charge Code |
9879923201
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$74.17 |
| Max. Negotiated Rate |
$190.82 |
| Rate for Payer: Aetna of VT Commercial |
$190.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$96.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$76.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$96.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$103.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$106.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$106.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$85.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$106.89
|
| Rate for Payer: Cash Price |
$101.50
|
| Rate for Payer: Cash Price |
$101.50
|
| Rate for Payer: Cigna Commercial |
$80.29
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$121.37
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$121.37
|
| Rate for Payer: Martins Point Health Care Commercial |
$74.17
|
| Rate for Payer: Multiplan Commercial |
$188.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$105.32
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$74.17
|
| Rate for Payer: United Healthcare Commercial |
$114.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.17
|
| Rate for Payer: United Healthcare VA CCN |
$74.17
|
|
|
SBSQ HOSPITAL CARE 50 MIN
|
Facility
|
OP
|
$290.00
|
|
|
Service Code
|
CPT 99233
|
| Hospital Charge Code |
9879923301
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$128.44 |
| Max. Negotiated Rate |
$275.50 |
| Rate for Payer: Aetna of VT Commercial |
$275.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$259.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$128.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$259.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$174.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$246.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$234.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$130.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$230.55
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cigna Commercial |
$232.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$232.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$232.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$130.50
|
| Rate for Payer: Multiplan Commercial |
$269.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$246.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$130.50
|
| Rate for Payer: United Healthcare Commercial |
$275.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.50
|
| Rate for Payer: United Healthcare VA CCN |
$130.50
|
|
|
SBSQ HOSPITAL CARE 50 MIN
|
Facility
|
IP
|
$290.00
|
|
|
Service Code
|
CPT 99233
|
| Hospital Charge Code |
9879923301
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$214.63 |
| Max. Negotiated Rate |
$275.50 |
| Rate for Payer: Aetna of VT Commercial |
$275.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$214.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$214.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$246.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$243.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$232.00
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cigna Commercial |
$232.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$232.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$232.00
|
| Rate for Payer: Multiplan Commercial |
$269.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$246.50
|
| Rate for Payer: United Healthcare Commercial |
$275.50
|
|
|
SBSQ HOSPITAL CARE 50 MIN
|
Professional
|
Both
|
$290.00
|
|
|
Service Code
|
CPT 99233
|
| Hospital Charge Code |
9879923301
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$110.99 |
| Max. Negotiated Rate |
$272.60 |
| Rate for Payer: Aetna of VT Commercial |
$272.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$143.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$114.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$143.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$155.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$153.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$153.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$127.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$153.47
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cigna Commercial |
$120.79
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$181.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$181.04
|
| Rate for Payer: Martins Point Health Care Commercial |
$110.99
|
| Rate for Payer: Multiplan Commercial |
$269.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$157.61
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$110.99
|
| Rate for Payer: United Healthcare Commercial |
$170.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$110.99
|
| Rate for Payer: United Healthcare VA CCN |
$110.99
|
|
|
SBSQ NB EM PER DAY HOSP
|
Professional
|
Both
|
$152.00
|
|
|
Service Code
|
CPT 99462
|
| Hospital Charge Code |
9879946201
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$37.64 |
| Max. Negotiated Rate |
$142.88 |
| Rate for Payer: Aetna of VT Commercial |
$142.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$136.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$38.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$136.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$52.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$59.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$59.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$43.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$59.36
|
| Rate for Payer: Cash Price |
$76.00
|
| Rate for Payer: Cash Price |
$76.00
|
| Rate for Payer: Cigna Commercial |
$41.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$61.21
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$61.21
|
| Rate for Payer: Martins Point Health Care Commercial |
$37.64
|
| Rate for Payer: Multiplan Commercial |
$141.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$53.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$37.64
|
| Rate for Payer: United Healthcare Commercial |
$57.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$37.64
|
| Rate for Payer: United Healthcare VA CCN |
$37.64
|
|
|
SBSQ NB EM PER DAY HOSP
|
Facility
|
OP
|
$152.00
|
|
|
Service Code
|
CPT 99462
|
| Hospital Charge Code |
9879946201
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$67.32 |
| Max. Negotiated Rate |
$144.40 |
| Rate for Payer: Aetna of VT Commercial |
$144.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$136.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$67.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$136.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$91.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$129.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$123.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$68.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$120.84
|
| Rate for Payer: Cash Price |
$76.00
|
| Rate for Payer: Cigna Commercial |
$121.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$121.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$121.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$68.40
|
| Rate for Payer: Multiplan Commercial |
$141.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$129.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$68.40
|
| Rate for Payer: United Healthcare Commercial |
$144.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$68.40
|
| Rate for Payer: United Healthcare VA CCN |
$68.40
|
|
|
SBSQ NB EM PER DAY HOSP
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
CPT 99462
|
| Hospital Charge Code |
9879946201
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$112.50 |
| Max. Negotiated Rate |
$144.40 |
| Rate for Payer: Aetna of VT Commercial |
$144.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$112.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$112.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$129.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$127.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$121.60
|
| Rate for Payer: Cash Price |
$76.00
|
| Rate for Payer: Cigna Commercial |
$121.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$121.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$121.60
|
| Rate for Payer: Multiplan Commercial |
$141.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$129.20
|
| Rate for Payer: United Healthcare Commercial |
$144.40
|
|
|
SBSQ NURS CARE/DAY STABLE 10M
|
Facility
|
IP
|
$135.00
|
|
|
Service Code
|
CPT 99307
|
| Hospital Charge Code |
9699930701
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$99.91 |
| Max. Negotiated Rate |
$128.25 |
| Rate for Payer: Aetna of VT Commercial |
$128.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$99.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$99.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$114.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$113.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$108.00
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$108.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$108.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$108.00
|
| Rate for Payer: Multiplan Commercial |
$125.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$114.75
|
| Rate for Payer: United Healthcare Commercial |
$128.25
|
|
|
SBSQ NURS CARE/DAY STABLE 10M
|
Professional
|
Both
|
$135.00
|
|
|
Service Code
|
CPT 99307
|
| Hospital Charge Code |
9699930701
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$37.76 |
| Max. Negotiated Rate |
$126.90 |
| Rate for Payer: Aetna of VT Commercial |
$126.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$49.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$38.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$49.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$52.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$63.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$63.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$43.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$63.70
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$41.34
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$61.21
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$61.21
|
| Rate for Payer: Martins Point Health Care Commercial |
$37.76
|
| Rate for Payer: Multiplan Commercial |
$125.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$53.63
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$37.77
|
| Rate for Payer: United Healthcare Commercial |
$58.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$37.77
|
| Rate for Payer: United Healthcare VA CCN |
$37.77
|
|
|
SBSQ NURS CARE/DAY STABLE 10M
|
Facility
|
OP
|
$135.00
|
|
|
Service Code
|
CPT 99307
|
| Hospital Charge Code |
9699930701
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$59.79 |
| Max. Negotiated Rate |
$128.25 |
| Rate for Payer: Aetna of VT Commercial |
$128.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$120.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$59.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$120.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$81.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$114.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$109.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$60.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$107.33
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$108.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$108.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$108.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$60.75
|
| Rate for Payer: Multiplan Commercial |
$125.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$114.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$60.75
|
| Rate for Payer: United Healthcare Commercial |
$128.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.75
|
| Rate for Payer: United Healthcare VA CCN |
$60.75
|
|
|
SBSQ NURS DAY UNST/NEWPROB 35M
|
Facility
|
OP
|
$231.00
|
|
|
Service Code
|
CPT 99310
|
| Hospital Charge Code |
9699931001
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$102.31 |
| Max. Negotiated Rate |
$219.45 |
| Rate for Payer: Aetna of VT Commercial |
$219.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$206.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$102.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$206.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$139.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$196.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$187.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$103.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$183.65
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna Commercial |
$184.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$184.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$184.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$103.95
|
| Rate for Payer: Multiplan Commercial |
$214.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$196.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$103.95
|
| Rate for Payer: United Healthcare Commercial |
$219.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$103.95
|
| Rate for Payer: United Healthcare VA CCN |
$103.95
|
|
|
SBSQ NURS DAY UNST/NEWPROB 35M
|
Facility
|
IP
|
$231.00
|
|
|
Service Code
|
CPT 99310
|
| Hospital Charge Code |
9699931001
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$170.96 |
| Max. Negotiated Rate |
$219.45 |
| Rate for Payer: Aetna of VT Commercial |
$219.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$170.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$170.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$196.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$194.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$184.80
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna Commercial |
$184.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$184.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$184.80
|
| Rate for Payer: Multiplan Commercial |
$214.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$196.35
|
| Rate for Payer: United Healthcare Commercial |
$219.45
|
|
|
SBSQ NURS DAY UNST/NEWPROB 35M
|
Professional
|
Both
|
$231.00
|
|
|
Service Code
|
CPT 99310
|
| Hospital Charge Code |
9699931001
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$144.99 |
| Max. Negotiated Rate |
$236.07 |
| Rate for Payer: Aetna of VT Commercial |
$217.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$190.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$149.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$190.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$202.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$191.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$191.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$166.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$191.40
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna Commercial |
$157.66
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$236.07
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$236.07
|
| Rate for Payer: Martins Point Health Care Commercial |
$144.99
|
| Rate for Payer: Multiplan Commercial |
$214.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$205.89
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$144.99
|
| Rate for Payer: United Healthcare Commercial |
$223.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$144.99
|
| Rate for Payer: United Healthcare VA CCN |
$144.99
|
|
|
SBSQ NURSING DAY MIN COMPL 15
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
CPT 99308
|
| Hospital Charge Code |
9699930801
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$60.68 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Aetna of VT Commercial |
$130.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$122.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$60.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$122.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$82.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$116.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$110.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$61.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$108.92
|
| Rate for Payer: Cash Price |
$68.50
|
| Rate for Payer: Cigna Commercial |
$109.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$109.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$109.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$61.65
|
| Rate for Payer: Multiplan Commercial |
$127.41
|
| Rate for Payer: MVP Health Care of NY Commercial |
$116.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$61.65
|
| Rate for Payer: United Healthcare Commercial |
$130.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$61.65
|
| Rate for Payer: United Healthcare VA CCN |
$61.65
|
|
|
SBSQ NURSING DAY MIN COMPL 15
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
CPT 99308
|
| Hospital Charge Code |
9699930801
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$101.39 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Aetna of VT Commercial |
$130.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$101.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$101.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$116.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$115.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$109.60
|
| Rate for Payer: Cash Price |
$68.50
|
| Rate for Payer: Cigna Commercial |
$109.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$109.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$109.60
|
| Rate for Payer: Multiplan Commercial |
$127.41
|
| Rate for Payer: MVP Health Care of NY Commercial |
$116.45
|
| Rate for Payer: United Healthcare Commercial |
$130.15
|
|
|
SBSQ NURSING DAY MIN COMPL 15
|
Professional
|
Both
|
$137.00
|
|
|
Service Code
|
CPT 99308
|
| Hospital Charge Code |
9699930801
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$70.37 |
| Max. Negotiated Rate |
$128.78 |
| Rate for Payer: Aetna of VT Commercial |
$128.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$92.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$72.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$92.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$98.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$97.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$97.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$80.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$97.97
|
| Rate for Payer: Cash Price |
$68.50
|
| Rate for Payer: Cash Price |
$68.50
|
| Rate for Payer: Cigna Commercial |
$76.52
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$114.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$114.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$70.37
|
| Rate for Payer: Multiplan Commercial |
$127.41
|
| Rate for Payer: MVP Health Care of NY Commercial |
$99.93
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$70.37
|
| Rate for Payer: United Healthcare Commercial |
$108.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$70.37
|
| Rate for Payer: United Healthcare VA CCN |
$70.37
|
|
