|
SL DTAP-IPV VACCINE 4-6 YRS IM
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 90696 SL
|
| Hospital Charge Code |
6369069601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$172.76 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$172.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$172.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$61.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$61.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$61.15
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$85.83
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$85.83
|
| Rate for Payer: Martins Point Health Care Commercial |
$67.83
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare VA CCN |
$85.00
|
|
|
SL DTAP VACCINE < 7 YRS IM
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
6369070001
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$81.37 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$81.37
|
| 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 |
$81.37
|
| 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
|
|
|
SL DTAP VACCINE < 7 YRS IM
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
6369070001
|
|
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
|
|
|
SL DTAP VACCINE < 7 YRS IM
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
6369070001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$81.37 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$81.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$81.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$37.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$37.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$37.54
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$40.26
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$40.26
|
| Rate for Payer: Martins Point Health Care Commercial |
$31.79
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare VA CCN |
$46.00
|
|
|
SL DTAP VACCINE < 7 YRS IM
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 90700 SL
|
| Hospital Charge Code |
6369070001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$81.37 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$81.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$81.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$37.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$37.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$37.54
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$40.26
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$40.26
|
| Rate for Payer: Martins Point Health Care Commercial |
$31.79
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare VA CCN |
$46.00
|
|
|
SLEEP STUDY UNATT&RESP EFFT
|
Facility
|
OP
|
$90.68
|
|
|
Service Code
|
CPT 95806
|
| Hospital Charge Code |
9209580601
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$40.16 |
| Max. Negotiated Rate |
$86.15 |
| Rate for Payer: Aetna of VT Commercial |
$86.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$81.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$40.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$81.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$54.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$77.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$73.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$40.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$72.09
|
| Rate for Payer: Cash Price |
$45.34
|
| Rate for Payer: Cigna Commercial |
$72.54
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$72.54
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$72.54
|
| Rate for Payer: Martins Point Health Care Commercial |
$40.81
|
| Rate for Payer: Multiplan Commercial |
$84.33
|
| Rate for Payer: MVP Health Care of NY Commercial |
$77.08
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$40.81
|
| Rate for Payer: United Healthcare Commercial |
$86.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$40.81
|
| Rate for Payer: United Healthcare VA CCN |
$40.81
|
|
|
SLEEP STUDY UNATT&RESP EFFT
|
Professional
|
Both
|
$488.05
|
|
|
Service Code
|
CPT 54050
|
| Hospital Charge Code |
7409580601
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$102.87 |
| Max. Negotiated Rate |
$458.77 |
| Rate for Payer: Aetna of VT Commercial |
$458.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$437.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$105.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$437.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$144.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$196.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$196.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$118.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$196.38
|
| Rate for Payer: Cash Price |
$244.02
|
| Rate for Payer: Cash Price |
$244.02
|
| Rate for Payer: Cigna Commercial |
$178.30
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$225.78
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$225.78
|
| Rate for Payer: Martins Point Health Care Commercial |
$138.84
|
| Rate for Payer: Multiplan Commercial |
$453.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$146.08
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$102.87
|
| Rate for Payer: United Healthcare Commercial |
$158.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$102.87
|
| Rate for Payer: United Healthcare VA CCN |
$102.87
|
|
|
SLEEP STUDY UNATT&RESP EFFT
|
Facility
|
IP
|
$488.05
|
|
|
Service Code
|
CPT 95806
|
| Hospital Charge Code |
7409580601
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$361.21 |
| Max. Negotiated Rate |
$463.65 |
| Rate for Payer: Aetna of VT Commercial |
$463.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$361.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$361.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$414.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$409.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$390.44
|
| Rate for Payer: Cash Price |
$244.02
|
| Rate for Payer: Cigna Commercial |
$390.44
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$390.44
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$390.44
|
| Rate for Payer: Multiplan Commercial |
$453.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$414.84
|
| Rate for Payer: United Healthcare Commercial |
$463.65
|
|
|
SLEEP STUDY UNATT&RESP EFFT
|
Facility
|
OP
|
$488.05
|
|
|
Service Code
|
CPT 95806
|
| Hospital Charge Code |
7409580601
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$216.16 |
| Max. Negotiated Rate |
$463.65 |
| Rate for Payer: Aetna of VT Commercial |
$463.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$437.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$216.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$437.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$293.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$414.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$395.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$219.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$388.00
|
| Rate for Payer: Cash Price |
$244.02
|
| Rate for Payer: Cigna Commercial |
$390.44
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$390.44
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$390.44
|
| Rate for Payer: Martins Point Health Care Commercial |
$219.62
|
| Rate for Payer: Multiplan Commercial |
$453.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$414.84
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$219.62
|
| Rate for Payer: United Healthcare Commercial |
$463.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$219.62
|
| Rate for Payer: United Healthcare VA CCN |
$219.62
|
|
|
SLEEP STUDY UNATT&RESP EFFT
|
Facility
|
IP
|
$90.68
|
|
|
Service Code
|
CPT 95806
|
| Hospital Charge Code |
9209580601
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$67.11 |
| Max. Negotiated Rate |
$86.15 |
| Rate for Payer: Aetna of VT Commercial |
$86.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$67.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$67.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$77.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$76.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$72.54
|
| Rate for Payer: Cash Price |
$45.34
|
| Rate for Payer: Cigna Commercial |
$72.54
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$72.54
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$72.54
|
| Rate for Payer: Multiplan Commercial |
$84.33
|
| Rate for Payer: MVP Health Care of NY Commercial |
$77.08
|
| Rate for Payer: United Healthcare Commercial |
$86.15
|
|
|
SL FLUCELVAX CCIIV3 .05ML IM
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 90661
|
| Hospital Charge Code |
6369066101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$101.34 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$101.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$50.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$101.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$69.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$36.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$36.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$56.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$36.85
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$51.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$51.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$36.85
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$49.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$49.50
|
| Rate for Payer: United Healthcare Commercial |
$76.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.50
|
| Rate for Payer: United Healthcare VA CCN |
$49.50
|
|
|
SL FLUCELVAX CCIIV3 .05ML IM
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90661
|
| Hospital Charge Code |
6369066101
|
|
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
|
|
|
SL FLUCELVAX CCIIV3 .05ML IM
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90661
|
| Hospital Charge Code |
6369066101
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$101.34 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$101.34
|
| 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 |
$101.34
|
| 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 |
$49.50
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
SL FLU VAC TRV LIVE INTRANASAL
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90660
|
| Hospital Charge Code |
6369066001
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$79.39 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$79.39
|
| 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 |
$79.39
|
| 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 |
$29.71
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
SL FLU VAC TRV LIVE INTRANASAL
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 90660
|
| Hospital Charge Code |
6369066001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$79.39 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$79.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$30.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$79.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$41.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$28.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$28.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$34.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$28.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$40.10
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$40.10
|
| Rate for Payer: Martins Point Health Care Commercial |
$28.87
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$29.71
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$29.71
|
| Rate for Payer: United Healthcare Commercial |
$45.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.71
|
| Rate for Payer: United Healthcare VA CCN |
$29.71
|
|
|
SL FLU VAC TRV LIVE INTRANASAL
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90660
|
| Hospital Charge Code |
6369066001
|
|
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
|
|
|
SL HEP A/HEP B VACC ADULT IM
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90636 SL
|
| Hospital Charge Code |
6369063602
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$364.18 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$364.18
|
| 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 |
$364.18
|
| 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
|
|
|
SL HEP A/HEP B VACC ADULT IM
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90636 SL
|
| Hospital Charge Code |
6369063602
|
|
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
|
|
|
SL HEP A/HEP B VACC ADULT IM
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 90636 SL
|
| Hospital Charge Code |
6369063602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$364.18 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$364.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$364.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$129.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$129.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$129.28
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$178.43
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$178.43
|
| Rate for Payer: Martins Point Health Care Commercial |
$140.38
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare VA CCN |
$130.00
|
|
|
SL HEP A VAC ADULT IM
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90632 SL
|
| Hospital Charge Code |
6369063202
|
|
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
|
|
|
SL HEP A VAC ADULT IM
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 90632 SL
|
| Hospital Charge Code |
6369063202
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$198.44 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$198.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$198.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$89.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$89.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$89.47
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$99.46
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$99.46
|
| Rate for Payer: Martins Point Health Care Commercial |
$72.16
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$73.79
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
SL HEP A VAC ADULT IM
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90632 SL
|
| Hospital Charge Code |
6369063202
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$198.44 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$198.44
|
| 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 |
$198.44
|
| 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
|
|
|
SL HEPA VACC PED/ADOL 2 DOSE
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90633 SL
|
| Hospital Charge Code |
6369063301
|
|
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
|
|
|
SL HEPA VACC PED/ADOL 2 DOSE
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 90633 SL
|
| Hospital Charge Code |
6369063301
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$106.84 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$106.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$106.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$44.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$44.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$44.67
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$53.67
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$53.67
|
| Rate for Payer: Martins Point Health Care Commercial |
$41.33
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare VA CCN |
$56.00
|
|
|
SL HEPA VACC PED/ADOL 2 DOSE
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90633 SL
|
| Hospital Charge Code |
6369063301
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$106.84 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$106.84
|
| 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 |
$106.84
|
| 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
|
|
