|
ADM PRQ ID SUBQ/IM NJXS 1 VAC
|
Professional
|
Both
|
$21.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
7719047101
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$18.81 |
| Max. Negotiated Rate |
$34.24 |
| Rate for Payer: Aetna of VT Commercial |
$19.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$18.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$20.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$18.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$27.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$34.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$34.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$22.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$34.24
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cigna Commercial |
$20.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$31.89
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$31.89
|
| Rate for Payer: Martins Point Health Care Commercial |
$19.79
|
| Rate for Payer: Multiplan Commercial |
$19.53
|
| Rate for Payer: MVP Health Care of NY Commercial |
$28.12
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$19.80
|
| Rate for Payer: United Healthcare Commercial |
$30.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.80
|
| Rate for Payer: United Healthcare VA CCN |
$19.80
|
|
|
ADM PRQ ID SUBQ/IM NJXS 1 VAC
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
7719047101
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.54 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Aetna of VT Commercial |
$19.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$15.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$15.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$17.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$17.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$16.80
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cigna Commercial |
$16.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$16.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$16.80
|
| Rate for Payer: Multiplan Commercial |
$19.53
|
| Rate for Payer: MVP Health Care of NY Commercial |
$17.85
|
| Rate for Payer: United Healthcare Commercial |
$19.95
|
|
|
ADM PRQ ID SUBQ/IM NJXS 1 VAC
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
7719047101
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$9.30 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Aetna of VT Commercial |
$19.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$18.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$9.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$18.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$12.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$17.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$17.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$9.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$16.70
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cigna Commercial |
$16.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$16.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$16.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$9.45
|
| Rate for Payer: Multiplan Commercial |
$19.53
|
| Rate for Payer: MVP Health Care of NY Commercial |
$17.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$9.45
|
| Rate for Payer: United Healthcare Commercial |
$19.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.45
|
| Rate for Payer: United Healthcare VA CCN |
$9.45
|
|
|
ADM PRQ ID SUBQ/IM NJXS EA VAC
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
7719047201
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.54 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Aetna of VT Commercial |
$19.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$15.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$15.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$17.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$17.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$16.80
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cigna Commercial |
$16.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$16.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$16.80
|
| Rate for Payer: Multiplan Commercial |
$19.53
|
| Rate for Payer: MVP Health Care of NY Commercial |
$17.85
|
| Rate for Payer: United Healthcare Commercial |
$19.95
|
|
|
ADM PRQ ID SUBQ/IM NJXS EA VAC
|
Professional
|
Both
|
$21.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
7719047201
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$14.01 |
| Max. Negotiated Rate |
$22.62 |
| Rate for Payer: Aetna of VT Commercial |
$19.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$18.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$14.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$18.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$19.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$17.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$17.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$16.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$17.73
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cigna Commercial |
$14.42
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$22.62
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$22.62
|
| Rate for Payer: Martins Point Health Care Commercial |
$14.01
|
| Rate for Payer: Multiplan Commercial |
$19.53
|
| Rate for Payer: MVP Health Care of NY Commercial |
$19.89
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$14.01
|
| Rate for Payer: United Healthcare Commercial |
$21.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.01
|
| Rate for Payer: United Healthcare VA CCN |
$14.01
|
|
|
ADM PRQ ID SUBQ/IM NJXS EA VAC
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
7719047201
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$9.30 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Aetna of VT Commercial |
$19.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$18.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$9.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$18.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$12.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$17.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$17.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$9.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$16.70
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cigna Commercial |
$16.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$16.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$16.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$9.45
|
| Rate for Payer: Multiplan Commercial |
$19.53
|
| Rate for Payer: MVP Health Care of NY Commercial |
$17.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$9.45
|
| Rate for Payer: United Healthcare Commercial |
$19.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.45
|
| Rate for Payer: United Healthcare VA CCN |
$9.45
|
|
|
ADM SARSCOV2 100MCG/0.5ML1ST
|
Facility
|
OP
|
$57.90
|
|
|
Service Code
|
CPT 0011A
|
| Hospital Charge Code |
7710011A01
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$25.64 |
| Max. Negotiated Rate |
$55.01 |
| Rate for Payer: Aetna of VT Commercial |
$55.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$51.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$25.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$51.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$34.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$49.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$46.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$26.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$46.03
|
| Rate for Payer: Cash Price |
$28.95
|
| Rate for Payer: Cigna Commercial |
$46.32
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$46.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$46.32
|
| Rate for Payer: Martins Point Health Care Commercial |
$26.05
|
| Rate for Payer: Multiplan Commercial |
$53.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$49.22
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$26.05
|
| Rate for Payer: United Healthcare Commercial |
$55.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.05
|
| Rate for Payer: United Healthcare VA CCN |
$26.05
|
|
|
ADM SARSCOV2 100MCG/0.5ML1ST
|
Facility
|
IP
|
$57.90
|
|
|
Service Code
|
CPT 0011A
|
| Hospital Charge Code |
7710011A01
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$42.85 |
| Max. Negotiated Rate |
$55.01 |
| Rate for Payer: Aetna of VT Commercial |
$55.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$42.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$42.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$49.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$48.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$46.32
|
| Rate for Payer: Cash Price |
$28.95
|
| Rate for Payer: Cigna Commercial |
$46.32
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$46.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$46.32
|
| Rate for Payer: Multiplan Commercial |
$53.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$49.22
|
| Rate for Payer: United Healthcare Commercial |
$55.01
|
|
|
ADM SARSCOV2 100MCG/0.5ML1ST
|
Professional
|
Both
|
$57.90
|
|
|
Service Code
|
CPT 0011A
|
| Hospital Charge Code |
7710011A01
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$23.16 |
| Max. Negotiated Rate |
$72.06 |
| Rate for Payer: Aetna of VT Commercial |
$54.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$51.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$51.87
|
| Rate for Payer: Cash Price |
$28.95
|
| Rate for Payer: Cash Price |
$28.95
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$72.06
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$72.06
|
| Rate for Payer: Multiplan Commercial |
$53.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$45.00
|
| Rate for Payer: United Healthcare Commercial |
$58.35
|
| Rate for Payer: United Healthcare VA CCN |
$23.16
|
|
|
ADM SARSCOV2 30MCG/0.3ML 1ST
|
Professional
|
Both
|
$57.90
|
|
|
Service Code
|
CPT 0001A
|
| Hospital Charge Code |
7710001A01
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$23.16 |
| Max. Negotiated Rate |
$54.43 |
| Rate for Payer: Aetna of VT Commercial |
$54.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$51.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$51.87
|
| Rate for Payer: Cash Price |
$28.95
|
| Rate for Payer: Multiplan Commercial |
$53.85
|
| Rate for Payer: United Healthcare Commercial |
$49.22
|
| Rate for Payer: United Healthcare VA CCN |
$23.16
|
|
|
ADM SARSCOV2 30MCG/0.3ML 1ST
|
Facility
|
OP
|
$57.90
|
|
|
Service Code
|
CPT 0001A
|
| Hospital Charge Code |
7710001A01
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$25.64 |
| Max. Negotiated Rate |
$55.01 |
| Rate for Payer: Aetna of VT Commercial |
$55.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$51.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$25.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$51.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$34.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$49.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$46.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$26.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$46.03
|
| Rate for Payer: Cash Price |
$28.95
|
| Rate for Payer: Cigna Commercial |
$46.32
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$46.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$46.32
|
| Rate for Payer: Martins Point Health Care Commercial |
$26.05
|
| Rate for Payer: Multiplan Commercial |
$53.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$49.22
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$26.05
|
| Rate for Payer: United Healthcare Commercial |
$55.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.05
|
| Rate for Payer: United Healthcare VA CCN |
$26.05
|
|
|
ADM SARSCOV2 30MCG/0.3ML 1ST
|
Facility
|
IP
|
$57.90
|
|
|
Service Code
|
CPT 0001A
|
| Hospital Charge Code |
7710001A01
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$42.85 |
| Max. Negotiated Rate |
$55.01 |
| Rate for Payer: Aetna of VT Commercial |
$55.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$42.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$42.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$49.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$48.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$46.32
|
| Rate for Payer: Cash Price |
$28.95
|
| Rate for Payer: Cigna Commercial |
$46.32
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$46.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$46.32
|
| Rate for Payer: Multiplan Commercial |
$53.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$49.22
|
| Rate for Payer: United Healthcare Commercial |
$55.01
|
|
|
ADM SARSCOV2 30MCG/0.3ML 2ND
|
Facility
|
OP
|
$57.90
|
|
|
Service Code
|
CPT 0002A
|
| Hospital Charge Code |
7710002A01
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$25.64 |
| Max. Negotiated Rate |
$55.01 |
| Rate for Payer: Aetna of VT Commercial |
$55.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$51.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$25.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$51.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$34.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$49.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$46.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$26.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$46.03
|
| Rate for Payer: Cash Price |
$28.95
|
| Rate for Payer: Cigna Commercial |
$46.32
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$46.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$46.32
|
| Rate for Payer: Martins Point Health Care Commercial |
$26.05
|
| Rate for Payer: Multiplan Commercial |
$53.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$49.22
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$26.05
|
| Rate for Payer: United Healthcare Commercial |
$55.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.05
|
| Rate for Payer: United Healthcare VA CCN |
$26.05
|
|
|
ADM SARSCOV2 30MCG/0.3ML 2ND
|
Professional
|
Both
|
$57.90
|
|
|
Service Code
|
CPT 0002A
|
| Hospital Charge Code |
7710002A01
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$23.16 |
| Max. Negotiated Rate |
$54.43 |
| Rate for Payer: Aetna of VT Commercial |
$54.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$51.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$51.87
|
| Rate for Payer: Cash Price |
$28.95
|
| Rate for Payer: Multiplan Commercial |
$53.85
|
| Rate for Payer: United Healthcare Commercial |
$49.22
|
| Rate for Payer: United Healthcare VA CCN |
$23.16
|
|
|
ADM SARSCOV2 30MCG/0.3ML 2ND
|
Facility
|
IP
|
$57.90
|
|
|
Service Code
|
CPT 0002A
|
| Hospital Charge Code |
7710002A01
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$42.85 |
| Max. Negotiated Rate |
$55.01 |
| Rate for Payer: Aetna of VT Commercial |
$55.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$42.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$42.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$49.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$48.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$46.32
|
| Rate for Payer: Cash Price |
$28.95
|
| Rate for Payer: Cigna Commercial |
$46.32
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$46.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$46.32
|
| Rate for Payer: Multiplan Commercial |
$53.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$49.22
|
| Rate for Payer: United Healthcare Commercial |
$55.01
|
|
|
ADM SARSCOV2 30MCG/0.3ML 3RD
|
Facility
|
OP
|
$44.46
|
|
| Hospital Charge Code |
7710003A01
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$19.69 |
| Max. Negotiated Rate |
$42.24 |
| Rate for Payer: Aetna of VT Commercial |
$42.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$39.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$19.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$39.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$26.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$37.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$36.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$20.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$35.35
|
| Rate for Payer: Cash Price |
$22.23
|
| Rate for Payer: Cigna Commercial |
$35.57
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$35.57
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$35.57
|
| Rate for Payer: Martins Point Health Care Commercial |
$20.01
|
| Rate for Payer: Multiplan Commercial |
$41.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$37.79
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$20.01
|
| Rate for Payer: United Healthcare Commercial |
$42.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.01
|
| Rate for Payer: United Healthcare VA CCN |
$20.01
|
|
|
ADM SARSCOV2 30MCG/0.3ML 3RD
|
Facility
|
IP
|
$44.46
|
|
| Hospital Charge Code |
7710003A01
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$32.90 |
| Max. Negotiated Rate |
$42.24 |
| Rate for Payer: Aetna of VT Commercial |
$42.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$32.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$32.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$37.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$37.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$35.57
|
| Rate for Payer: Cash Price |
$22.23
|
| Rate for Payer: Cigna Commercial |
$35.57
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$35.57
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$35.57
|
| Rate for Payer: Multiplan Commercial |
$41.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$37.79
|
| Rate for Payer: United Healthcare Commercial |
$42.24
|
|
|
ADM SARSCOV2 30MCG/0.3ML 3RD
|
Professional
|
Both
|
$44.46
|
|
| Hospital Charge Code |
7710003A01
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$17.78 |
| Max. Negotiated Rate |
$41.79 |
| Rate for Payer: Aetna of VT Commercial |
$41.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$39.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$39.83
|
| Rate for Payer: Cash Price |
$22.23
|
| Rate for Payer: Multiplan Commercial |
$41.35
|
| Rate for Payer: United Healthcare Commercial |
$37.79
|
| Rate for Payer: United Healthcare VA CCN |
$17.78
|
|
|
ADM SARSCOV2 30MCG/0.3ML BST
|
Facility
|
IP
|
$57.90
|
|
|
Service Code
|
CPT 0004A
|
| Hospital Charge Code |
7710004A01
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$42.85 |
| Max. Negotiated Rate |
$55.01 |
| Rate for Payer: Aetna of VT Commercial |
$55.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$42.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$42.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$49.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$48.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$46.32
|
| Rate for Payer: Cash Price |
$28.95
|
| Rate for Payer: Cigna Commercial |
$46.32
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$46.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$46.32
|
| Rate for Payer: Multiplan Commercial |
$53.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$49.22
|
| Rate for Payer: United Healthcare Commercial |
$55.01
|
|
|
ADM SARSCOV2 30MCG/0.3ML BST
|
Facility
|
OP
|
$57.90
|
|
|
Service Code
|
CPT 0004A
|
| Hospital Charge Code |
7710004A01
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$25.64 |
| Max. Negotiated Rate |
$55.01 |
| Rate for Payer: Aetna of VT Commercial |
$55.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$51.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$25.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$51.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$34.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$49.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$46.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$26.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$46.03
|
| Rate for Payer: Cash Price |
$28.95
|
| Rate for Payer: Cigna Commercial |
$46.32
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$46.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$46.32
|
| Rate for Payer: Martins Point Health Care Commercial |
$26.05
|
| Rate for Payer: Multiplan Commercial |
$53.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$49.22
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$26.05
|
| Rate for Payer: United Healthcare Commercial |
$55.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.05
|
| Rate for Payer: United Healthcare VA CCN |
$26.05
|
|
|
ADM SARSCOV2 30MCG/0.3ML BST
|
Professional
|
Both
|
$57.90
|
|
|
Service Code
|
CPT 0004A
|
| Hospital Charge Code |
7710004A01
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$23.16 |
| Max. Negotiated Rate |
$54.43 |
| Rate for Payer: Aetna of VT Commercial |
$54.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$51.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$51.87
|
| Rate for Payer: Cash Price |
$28.95
|
| Rate for Payer: Multiplan Commercial |
$53.85
|
| Rate for Payer: United Healthcare Commercial |
$49.22
|
| Rate for Payer: United Healthcare VA CCN |
$23.16
|
|
|
ADM SARSCOV2 50MCG/0.25MLBST
|
Professional
|
Both
|
$57.90
|
|
|
Service Code
|
CPT 0064A
|
| Hospital Charge Code |
7710064A01
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$23.16 |
| Max. Negotiated Rate |
$72.06 |
| Rate for Payer: Aetna of VT Commercial |
$54.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$51.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$51.87
|
| Rate for Payer: Cash Price |
$28.95
|
| Rate for Payer: Cash Price |
$28.95
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$72.06
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$72.06
|
| Rate for Payer: Multiplan Commercial |
$53.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$45.00
|
| Rate for Payer: United Healthcare Commercial |
$58.35
|
| Rate for Payer: United Healthcare VA CCN |
$23.16
|
|
|
ADM SARSCOV2 50MCG/0.25MLBST
|
Facility
|
OP
|
$57.90
|
|
|
Service Code
|
CPT 0064A
|
| Hospital Charge Code |
7710064A01
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$25.64 |
| Max. Negotiated Rate |
$55.01 |
| Rate for Payer: Aetna of VT Commercial |
$55.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$51.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$25.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$51.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$34.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$49.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$46.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$26.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$46.03
|
| Rate for Payer: Cash Price |
$28.95
|
| Rate for Payer: Cigna Commercial |
$46.32
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$46.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$46.32
|
| Rate for Payer: Martins Point Health Care Commercial |
$26.05
|
| Rate for Payer: Multiplan Commercial |
$53.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$49.22
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$26.05
|
| Rate for Payer: United Healthcare Commercial |
$55.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.05
|
| Rate for Payer: United Healthcare VA CCN |
$26.05
|
|
|
ADM SARSCOV2 50MCG/0.25MLBST
|
Facility
|
IP
|
$57.90
|
|
|
Service Code
|
CPT 0064A
|
| Hospital Charge Code |
7710064A01
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$42.85 |
| Max. Negotiated Rate |
$55.01 |
| Rate for Payer: Aetna of VT Commercial |
$55.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$42.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$42.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$49.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$48.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$46.32
|
| Rate for Payer: Cash Price |
$28.95
|
| Rate for Payer: Cigna Commercial |
$46.32
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$46.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$46.32
|
| Rate for Payer: Multiplan Commercial |
$53.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$49.22
|
| Rate for Payer: United Healthcare Commercial |
$55.01
|
|
|
ADM SARSCV2 30MCG TRS-SUCR 1
|
Professional
|
Both
|
$57.90
|
|
|
Service Code
|
CPT 90480
|
| Hospital Charge Code |
7719048001
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$23.16 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna of VT Commercial |
$54.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$51.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$51.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$44.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$44.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$44.95
|
| Rate for Payer: Cash Price |
$28.95
|
| Rate for Payer: Cash Price |
$28.95
|
| Rate for Payer: Cigna Commercial |
$40.33
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$62.93
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$62.93
|
| Rate for Payer: Martins Point Health Care Commercial |
$44.44
|
| Rate for Payer: Multiplan Commercial |
$53.85
|
| Rate for Payer: United Healthcare Commercial |
$49.22
|
| Rate for Payer: United Healthcare VA CCN |
$23.16
|
|
