|
SL HEPA VACC PED/ADOL 3 DOSE
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90634 SL
|
| Hospital Charge Code |
6369063401
|
|
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
|
|
|
SL HEPA VACC PED/ADOL 3 DOSE
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 90634 SL
|
| Hospital Charge Code |
6369063401
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$177.39 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$177.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$177.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$44.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$44.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$44.68
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$32.51
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$32.51
|
| Rate for Payer: Martins Point Health Care Commercial |
$23.41
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare VA CCN |
$40.00
|
|
|
SL HEPA VACC PED/ADOL 3 DOSE
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90634 SL
|
| Hospital Charge Code |
6369063401
|
|
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 HEPB VACC 3 DOSE BIRTH-19YR
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 90744 SL
|
| Hospital Charge Code |
6369074402
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$87.09 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$87.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$87.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$80.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$80.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$80.85
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$43.99
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$43.99
|
| Rate for Payer: Martins Point Health Care Commercial |
$31.67
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$31.67
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
SL HEPB VACC 4 DOSE IMMUNSUP
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 90747 SL
|
| Hospital Charge Code |
6369074701
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$387.06 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$387.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$387.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$235.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$235.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$235.39
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$219.67
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$219.67
|
| Rate for Payer: Martins Point Health Care Commercial |
$140.75
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$140.75
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
SL HEPB VACC 4 DOSE IMMUNSUP
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90747 SL
|
| Hospital Charge Code |
6369074701
|
|
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 HEPB VACC 4 DOSE IMMUNSUP
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90747 SL
|
| Hospital Charge Code |
6369074701
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$387.06 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$387.06
|
| 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 |
$387.06
|
| 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 HEPB VACCINE 3 DOSE ADULT
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90746 SL
|
| Hospital Charge Code |
6369074602
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$193.55 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$193.55
|
| 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 |
$193.55
|
| 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 HEPB VACCINE 3 DOSE ADULT
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 90746 SL
|
| Hospital Charge Code |
6369074602
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$193.55 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$193.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$193.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$92.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$92.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$92.78
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$108.75
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$108.75
|
| Rate for Payer: Martins Point Health Care Commercial |
$70.38
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$70.38
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
SL HEPB VACCINE 3 DOSE ADULT
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90746 SL
|
| Hospital Charge Code |
6369074602
|
|
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 HIB PRP-T VAC 4 DOSE IM
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 90648
|
| Hospital Charge Code |
6369064801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$36.22 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$36.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$36.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$34.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$34.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$34.65
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$17.07
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$17.07
|
| Rate for Payer: Martins Point Health Care Commercial |
$14.08
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare VA CCN |
$33.00
|
|
|
SL IIV3 VAC NO PRSV .05 ML IM
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90656
|
| Hospital Charge Code |
6369065602
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$61.46 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$61.46
|
| 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 |
$61.46
|
| 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 |
$23.22
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
SL IIV3 VAC NO PRSV .05 ML IM
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90656
|
| Hospital Charge Code |
6369065602
|
|
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 IIV3 VAC NO PRSV .05 ML IM
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 90656
|
| Hospital Charge Code |
6369065602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$61.46 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$61.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$23.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$61.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$32.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$24.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$24.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$26.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$24.46
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$31.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$31.04
|
| Rate for Payer: Martins Point Health Care Commercial |
$22.35
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$23.22
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$23.22
|
| Rate for Payer: United Healthcare Commercial |
$35.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23.22
|
| Rate for Payer: United Healthcare VA CCN |
$23.22
|
|
|
SL IIV4 VACC NO PRSV 0.5 ML
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90686 SL
|
| Hospital Charge Code |
6369068602
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$54.26 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$54.26
|
| 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 |
$54.26
|
| 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 IIV4 VACC NO PRSV 0.5 ML
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 90686 SL
|
| Hospital Charge Code |
6369068602
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$54.26 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$54.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$54.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$25.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$25.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$25.64
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$31.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$31.04
|
| Rate for Payer: Martins Point Health Care Commercial |
$22.35
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
SL IIV4 VACC NO PRSV 0.5 ML
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90686 SL
|
| Hospital Charge Code |
6369068602
|
|
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
|
|
|
SLING ULTRA M
|
Facility
|
OP
|
$43.21
|
|
|
Service Code
|
HCPCS L3670
|
| Hospital Charge Code |
2740021681
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$41.05 |
| Rate for Payer: Aetna of VT Commercial |
$41.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$38.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$38.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$26.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$36.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$35.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$19.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$34.35
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$34.57
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$34.57
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$34.57
|
| Rate for Payer: Martins Point Health Care Commercial |
$19.44
|
| Rate for Payer: Multiplan Commercial |
$40.19
|
| Rate for Payer: MVP Health Care of NY Commercial |
$36.73
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$19.44
|
| Rate for Payer: United Healthcare Commercial |
$41.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.44
|
| Rate for Payer: United Healthcare VA CCN |
$19.44
|
|
|
SLING ULTRA M
|
Professional
|
Both
|
$43.21
|
|
|
Service Code
|
HCPCS L3670
|
| Hospital Charge Code |
2740021681
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$38.71 |
| Max. Negotiated Rate |
$191.76 |
| Rate for Payer: Aetna of VT Commercial |
$40.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$38.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$128.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$38.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$174.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$143.36
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$100.93
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$100.93
|
| Rate for Payer: Martins Point Health Care Commercial |
$124.66
|
| Rate for Payer: Multiplan Commercial |
$40.19
|
| Rate for Payer: MVP Health Care of NY Commercial |
$177.02
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$124.66
|
| Rate for Payer: United Healthcare Commercial |
$191.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$124.66
|
| Rate for Payer: United Healthcare VA CCN |
$124.66
|
|
|
SLING ULTRA M
|
Facility
|
IP
|
$43.21
|
|
|
Service Code
|
HCPCS L3670
|
| Hospital Charge Code |
2740021681
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$31.98 |
| Max. Negotiated Rate |
$41.05 |
| Rate for Payer: Aetna of VT Commercial |
$41.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$31.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$31.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$36.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$36.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$34.57
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$34.57
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$34.57
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$34.57
|
| Rate for Payer: Multiplan Commercial |
$40.19
|
| Rate for Payer: MVP Health Care of NY Commercial |
$36.73
|
| Rate for Payer: United Healthcare Commercial |
$41.05
|
|
|
SL MEASLES,MUMPS,RUBELLA VACC
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 90707
|
| Hospital Charge Code |
6369070701
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$261.80 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$261.80
|
| 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 |
$261.80
|
| 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 MEASLES,MUMPS,RUBELLA VACC
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90707 SL
|
| Hospital Charge Code |
6369070701
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$261.80 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$261.80
|
| 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 |
$261.80
|
| 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 MEASLES,MUMPS,RUBELLA VACC
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 90707 SL
|
| Hospital Charge Code |
6369070701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$261.80 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$261.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$261.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$102.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$102.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$102.47
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$130.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$130.50
|
| Rate for Payer: Martins Point Health Care Commercial |
$100.91
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare VA CCN |
$97.00
|
|
|
SL MEASLES,MUMPS,RUBELLA VACC
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90707 SL
|
| Hospital Charge Code |
6369070701
|
|
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 MEASLES,MUMPS,RUBELLA VACC
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
HCPCS 90707
|
| Hospital Charge Code |
6369070701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$261.80 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$261.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$261.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$102.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$102.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$102.47
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$130.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$130.50
|
| Rate for Payer: Martins Point Health Care Commercial |
$100.91
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare VA CCN |
$97.00
|
|
