|
DIPHENOXYLATE + ATROPINE 2.5 MG-0.025 MG
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41654098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.50
|
| Rate for Payer: Aetna Government |
$0.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.68
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
DIPHENOXYLATE + ATROPINE 2.5 MG-0.025 MG
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41644098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.50
|
| Rate for Payer: Aetna Government |
$0.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.68
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
DIPHENOXYLATE + ATROPINE 2.5 MG-0.025 MG
|
Facility
OP
|
$12.00
|
|
| Hospital Charge Code |
41640800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.60
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.00
|
| Rate for Payer: Aetna Government |
$6.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.16
|
| Rate for Payer: Group Health Inc Commercial |
$6.00
|
| Rate for Payer: Group Health Inc Medicare |
$4.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.80
|
|
|
DIPH/TET/PERT/POLIO 0.5ML SYR
|
Facility
OP
|
$103.00
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
41659577
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.05 |
| Max. Negotiated Rate |
$66.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$56.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$56.24
|
| Rate for Payer: Aetna Government |
$56.24
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$51.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$59.22
|
| Rate for Payer: Group Health Inc Commercial |
$51.50
|
| Rate for Payer: Group Health Inc Medicare |
$36.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$51.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$51.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$66.95
|
|
|
DIPH/TET/PERT/POLIO 0.5ML SYR
|
Facility
IP
|
$103.00
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
41659577
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.50 |
| Max. Negotiated Rate |
$51.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$51.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$51.50
|
|
|
DIPH/TET/PERT/POLIO 0.5ML SYR
|
Facility
OP
|
$103.00
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
41649577
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.05 |
| Max. Negotiated Rate |
$66.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$56.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$56.24
|
| Rate for Payer: Aetna Government |
$56.24
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$51.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$59.22
|
| Rate for Payer: Group Health Inc Commercial |
$51.50
|
| Rate for Payer: Group Health Inc Medicare |
$36.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$51.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$51.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$66.95
|
|
|
DIPH/TET/PERT/POLIO 0.5ML SYR
|
Facility
IP
|
$103.00
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
41649577
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.50 |
| Max. Negotiated Rate |
$51.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$51.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$51.50
|
|
|
DIPH/TET/PERT/POLIO HAEMB (VFC)
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
41659553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
DIPH/TET/PERT/POLIO HAEMB (VFC)
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
41659553
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$105.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$105.11
|
| Rate for Payer: Aetna Government |
$105.11
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
|
|
DIPH/TET/PERT/POLIO HAEMB(VFC)
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
41649553
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$105.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$105.11
|
| Rate for Payer: Aetna Government |
$105.11
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
|
|
DIPH/TET/PERT/POLIO HAEMB(VFC)
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
41649553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
DIPH/TET/PERT/POLIO/HEPB(VFC)SYR
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
41659552
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
DIPH/TET/PERT/POLIO/HEPB(VFC)SYR
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
41649552
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
DIPH/TET/PERT/POLIO/HEPB(VFC)SYR
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
41659552
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$93.35 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$93.35
|
| Rate for Payer: Aetna Government |
$93.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
|
|
DIPH/TET/PERT/POLIO/HEPB(VFC)SYR
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
41649552
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$93.35 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$93.35
|
| Rate for Payer: Aetna Government |
$93.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
|
|
DIPH/TET/PERT/POLIO (VFC) 0.5ML S
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
41659550
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$56.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$56.24
|
| Rate for Payer: Aetna Government |
$56.24
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
|
|
DIPH/TET/PERT/POLIO (VFC) 0.5ML S
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
41649550
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$56.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$56.24
|
| Rate for Payer: Aetna Government |
$56.24
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
|
|
DIPH/TET/PERT/POLIO (VFC) 0.5ML S
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
41659550
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
DIPH/TET/PERT/POLIO (VFC) 0.5ML S
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
41649550
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
DIPH/TET/PERT/POLIO (VFC) 0.5ML V
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
41659551
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
DIPH/TET/PERT/POLIO (VFC) 0.5ML V
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
41649551
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$56.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$56.24
|
| Rate for Payer: Aetna Government |
$56.24
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
|
|
DIPH/TET/PERT/POLIO (VFC) 0.5ML V
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
41649551
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
DIPH/TET/PERT/POLIO (VFC) 0.5ML V
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
41659551
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$56.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$56.24
|
| Rate for Payer: Aetna Government |
$56.24
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
|
|
DIPH/TET/PERT (VFC) 0.5ML SYR
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
41646909
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$27.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$27.70
|
| Rate for Payer: Aetna Government |
$27.70
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
|
|
DIPH/TET/PERT (VFC) 0.5ML SYR
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
41656909
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$27.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$27.70
|
| Rate for Payer: Aetna Government |
$27.70
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
|
