|
SL PNEUMOCOCCAL 23-VAL P-SAC
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
6369073201
|
|
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 PNEUMOCOCCAL 23-VAL P-SAC
|
Professional
|
Both
|
$301.00
|
|
|
Service Code
|
CPT 90732 SL
|
| Hospital Charge Code |
6369073201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$120.40 |
| Max. Negotiated Rate |
$367.04 |
| Rate for Payer: Aetna of VT Commercial |
$282.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$367.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$367.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$148.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$148.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$148.09
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$185.39
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$185.39
|
| Rate for Payer: Martins Point Health Care Commercial |
$133.47
|
| Rate for Payer: Multiplan Commercial |
$279.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$133.47
|
| Rate for Payer: United Healthcare Commercial |
$255.85
|
| Rate for Payer: United Healthcare VA CCN |
$120.40
|
|
|
SL PNEUMOCOCCAL 23-VAL P-SAC
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90732 SL
|
| Hospital Charge Code |
6369073201
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$367.04 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$367.04
|
| 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 |
$367.04
|
| 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 PNEUMOCOCCAL 23-VAL P-SAC
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90732 SL
|
| Hospital Charge Code |
6369073201
|
|
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 PNEUMOCOCCAL 23-VAL P-SAC
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
6369073201
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$367.04 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$367.04
|
| 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 |
$367.04
|
| 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 |
$133.47
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
SL PNEUMOCOCCAL 23-VAL P-SAC
|
Professional
|
Both
|
$301.00
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
6369073201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$133.47 |
| Max. Negotiated Rate |
$367.04 |
| Rate for Payer: Aetna of VT Commercial |
$282.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$367.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$137.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$367.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$186.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$148.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$148.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$153.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$148.09
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$185.39
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$185.39
|
| Rate for Payer: Martins Point Health Care Commercial |
$133.47
|
| Rate for Payer: Multiplan Commercial |
$279.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$133.47
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$133.47
|
| Rate for Payer: United Healthcare Commercial |
$205.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$133.47
|
| Rate for Payer: United Healthcare VA CCN |
$133.47
|
|
|
SLP STDY UNATTENDED
|
Facility
|
OP
|
$257.47
|
|
|
Service Code
|
CPT G0398
|
| Hospital Charge Code |
9209580001
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$114.03 |
| Max. Negotiated Rate |
$244.60 |
| Rate for Payer: Aetna of VT Commercial |
$244.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$230.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$114.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$230.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$155.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$218.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$208.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$115.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$204.69
|
| Rate for Payer: Cash Price |
$128.74
|
| Rate for Payer: Cigna Commercial |
$205.98
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$205.98
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$205.98
|
| Rate for Payer: Martins Point Health Care Commercial |
$115.86
|
| Rate for Payer: Multiplan Commercial |
$239.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$218.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$115.86
|
| Rate for Payer: United Healthcare Commercial |
$244.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$115.86
|
| Rate for Payer: United Healthcare VA CCN |
$115.86
|
|
|
SLP STDY UNATTENDED
|
Facility
|
IP
|
$257.47
|
|
|
Service Code
|
CPT G0398
|
| Hospital Charge Code |
9209580001
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$190.55 |
| Max. Negotiated Rate |
$244.60 |
| Rate for Payer: Aetna of VT Commercial |
$244.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$190.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$190.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$218.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$216.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$205.98
|
| Rate for Payer: Cash Price |
$128.74
|
| Rate for Payer: Cigna Commercial |
$205.98
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$205.98
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$205.98
|
| Rate for Payer: Multiplan Commercial |
$239.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$218.85
|
| Rate for Payer: United Healthcare Commercial |
$244.60
|
|
|
SL RSV MAB IM 50MG
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90378 SL
|
| Hospital Charge Code |
6369037801
|
|
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 RSV MAB IM 50MG
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90378 SL
|
| Hospital Charge Code |
6369037801
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$5,006.82 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,006.82
|
| 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 |
$5,006.82
|
| 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 RSV MAB IM 50MG
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 90378 SL
|
| Hospital Charge Code |
6369037801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$5,006.82 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,006.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,006.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$909.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$909.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$909.54
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,441.19
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,441.19
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,075.55
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare VA CCN |
$1,748.00
|
|
|
SL RSV MONOC ANTB SEASN 1 ML
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90381 SL
|
| Hospital Charge Code |
6369038101
|
|
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 RSV MONOC ANTB SEASN 1 ML
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90381 SL
|
| Hospital Charge Code |
6369038101
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$1,529.36 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,529.36
|
| 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 |
$1,529.36
|
| 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 RSV MONOC ANTB SEASN .5ML
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90380 SL
|
| Hospital Charge Code |
6369038001
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$1,529.36 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,529.36
|
| 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 |
$1,529.36
|
| 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 RSV MONOC ANTB SEASN .5ML
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90380 SL
|
| Hospital Charge Code |
6369038001
|
|
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 RSV MONOC ANTB SEASN .5ML
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 90380 SL
|
| Hospital Charge Code |
6369038001
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$1,529.36 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,529.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,529.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$669.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$669.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$669.41
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$736.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$736.32
|
| Rate for Payer: Martins Point Health Care Commercial |
$550.94
|
| 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 SARSCOV2 VAC 25MCG/.25ML IM
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 91321
|
| Hospital Charge Code |
6369132101
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$404.42 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$404.42
|
| 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 |
$404.42
|
| 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 SARSCOV2 VAC 25MCG/.25ML IM
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 91321
|
| Hospital Charge Code |
6369132101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$404.42 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$404.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$151.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$404.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$205.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$147.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$147.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$169.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$147.06
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$204.25
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$204.25
|
| Rate for Payer: Martins Point Health Care Commercial |
$147.06
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$147.06
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$147.06
|
| Rate for Payer: United Healthcare Commercial |
$226.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$147.06
|
| Rate for Payer: United Healthcare VA CCN |
$147.06
|
|
|
SL SARSCOV2 VAC 25MCG/.25ML IM
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 91321
|
| Hospital Charge Code |
6369132101
|
|
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 SARSCV2 VAC 10MCG TRS-SUC I
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 91319
|
| Hospital Charge Code |
6369131902
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$241.40 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$241.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$97.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$241.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$132.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$87.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$87.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$109.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$87.78
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$121.92
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$121.92
|
| Rate for Payer: Martins Point Health Care Commercial |
$87.78
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$94.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$94.80
|
| Rate for Payer: United Healthcare Commercial |
$145.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$94.80
|
| Rate for Payer: United Healthcare VA CCN |
$94.80
|
|
|
SL SARSCV2 VAC 10MCG TRS-SUC I
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 91319
|
| Hospital Charge Code |
6369131902
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$241.40 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$241.40
|
| 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 |
$241.40
|
| 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 SARSCV2 VAC 10MCG TRS-SUC I
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 91319
|
| Hospital Charge Code |
6369131902
|
|
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 SARSCV2 VAC 30MCG TRSSUC IM
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 91320
|
| Hospital Charge Code |
6369132004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$428.73 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$428.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$173.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$428.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$235.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$155.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$155.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$193.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$155.90
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$216.53
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$216.53
|
| Rate for Payer: Martins Point Health Care Commercial |
$155.90
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$168.37
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$168.37
|
| Rate for Payer: United Healthcare Commercial |
$259.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$168.37
|
| Rate for Payer: United Healthcare VA CCN |
$168.37
|
|
|
SL SARSCV2 VAC 30MCG TRSSUC IM
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 91320
|
| Hospital Charge Code |
6369132004
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$428.73 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$428.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.00
|
| 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 |
$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 SARSCV2 VAC 30MCG TRSSUC IM
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 91320
|
| Hospital Charge Code |
6369132004
|
|
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
|
|
