|
DIPHTHERIA + TETANUS + PERTUSSIS INJ (BO
|
Facility
IP
|
$74.00
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
41644662
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.00 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$37.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$37.00
|
|
|
DIPHTHERIA + TETANUS + PERTUSSIS INJ (DA
|
Facility
OP
|
$48.55
|
|
| Hospital Charge Code |
41654070
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.99 |
| Max. Negotiated Rate |
$31.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$26.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$24.28
|
| Rate for Payer: Aetna Government |
$24.28
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$24.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$27.92
|
| Rate for Payer: Group Health Inc Commercial |
$24.28
|
| Rate for Payer: Group Health Inc Medicare |
$16.99
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.28
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$31.56
|
|
|
DIPHTHERIA + TETANUS + PERTUSSIS INJ (DA
|
Facility
OP
|
$48.55
|
|
| Hospital Charge Code |
41644070
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.99 |
| Max. Negotiated Rate |
$31.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$26.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$24.28
|
| Rate for Payer: Aetna Government |
$24.28
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$24.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$27.92
|
| Rate for Payer: Group Health Inc Commercial |
$24.28
|
| Rate for Payer: Group Health Inc Medicare |
$16.99
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.28
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$31.56
|
|
|
DIPHTHERIA + TETANUS + PERTUSSIS INJ (DA
|
Facility
IP
|
$48.55
|
|
| Hospital Charge Code |
41654070
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.28 |
| Max. Negotiated Rate |
$24.28 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.28
|
|
|
DIPHTHERIA + TETANUS + PERTUSSIS INJ (DA
|
Facility
IP
|
$48.55
|
|
| Hospital Charge Code |
41644070
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.28 |
| Max. Negotiated Rate |
$24.28 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.28
|
|
|
DIPHTHERIA + TETANUS + PERTUSSIS INJ SYR
|
Facility
IP
|
$74.00
|
|
| Hospital Charge Code |
41644130
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.00 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$37.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$37.00
|
|
|
DIPHTHERIA + TETANUS + PERTUSSIS INJ SYR
|
Facility
OP
|
$74.00
|
|
| Hospital Charge Code |
41654130
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.90 |
| Max. Negotiated Rate |
$48.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$40.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$37.00
|
| Rate for Payer: Aetna Government |
$37.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$37.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$42.55
|
| Rate for Payer: Group Health Inc Commercial |
$37.00
|
| Rate for Payer: Group Health Inc Medicare |
$25.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$37.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$37.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$48.10
|
|
|
DIPHTHERIA + TETANUS + PERTUSSIS INJ SYR
|
Facility
OP
|
$74.00
|
|
| Hospital Charge Code |
41644130
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.90 |
| Max. Negotiated Rate |
$48.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$40.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$37.00
|
| Rate for Payer: Aetna Government |
$37.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$37.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$42.55
|
| Rate for Payer: Group Health Inc Commercial |
$37.00
|
| Rate for Payer: Group Health Inc Medicare |
$25.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$37.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$37.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$48.10
|
|
|
DIPHTHERIA + TETANUS + PERTUSSIS INJ SYR
|
Facility
IP
|
$74.00
|
|
| Hospital Charge Code |
41654130
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.00 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$37.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$37.00
|
|
|
DIPHTHERIA + TETANUS + PERTUSSIS + POLIO
|
Facility
OP
|
$94.10
|
|
| Hospital Charge Code |
41655060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.94 |
| Max. Negotiated Rate |
$75.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$51.76
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$47.05
|
| Rate for Payer: Aetna Government |
$47.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$75.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$63.99
|
| Rate for Payer: Group Health Inc Commercial |
$47.05
|
| Rate for Payer: Group Health Inc Medicare |
$32.94
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$47.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$47.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$61.16
|
|
|
DIPHTHERIA + TETANUS + PERTUSSIS + POLIO
|
Facility
IP
|
$135.98
|
|
| Hospital Charge Code |
41653275
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.99 |
| Max. Negotiated Rate |
$67.99 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$67.99
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$67.99
|
|
|
DIPHTHERIA + TETANUS + PERTUSSIS + POLIO
|
Facility
IP
|
$103.00
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
41655057
|
|
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
|
|
|
DIPHTHERIA + TETANUS + PERTUSSIS + POLIO
|
Facility
OP
|
$135.98
|
|
| Hospital Charge Code |
41653275
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.59 |
| Max. Negotiated Rate |
$88.39 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$74.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$67.99
|
| Rate for Payer: Aetna Government |
$67.99
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$67.99
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$78.19
|
| Rate for Payer: Group Health Inc Commercial |
$67.99
|
| Rate for Payer: Group Health Inc Medicare |
$47.59
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$67.99
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$67.99
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$88.39
|
|
|
DIPHTHERIA + TETANUS + PERTUSSIS + POLIO
|
Facility
OP
|
$135.98
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
41643275
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.59 |
| Max. Negotiated Rate |
$93.35 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$74.79
|
| 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 |
$67.99
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$78.19
|
| Rate for Payer: Group Health Inc Commercial |
$67.99
|
| Rate for Payer: Group Health Inc Medicare |
$47.59
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$67.99
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$67.99
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$88.39
|
|
|
DIPHTHERIA + TETANUS + PERTUSSIS + POLIO
|
Facility
OP
|
$94.10
|
|
| Hospital Charge Code |
41645060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.94 |
| Max. Negotiated Rate |
$75.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$51.76
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$47.05
|
| Rate for Payer: Aetna Government |
$47.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$75.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$63.99
|
| Rate for Payer: Group Health Inc Commercial |
$47.05
|
| Rate for Payer: Group Health Inc Medicare |
$32.94
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$47.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$47.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$61.16
|
|
|
DIPHTHERIA + TETANUS + PERTUSSIS + POLIO
|
Facility
OP
|
$103.00
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
41655057
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.05 |
| Max. Negotiated Rate |
$105.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$56.65
|
| 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 |
$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
|
|
|
DIPHTHERIA + TETANUS + PERTUSSIS + POLIO
|
Facility
IP
|
$135.98
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
41643275
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.99 |
| Max. Negotiated Rate |
$67.99 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$67.99
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$67.99
|
|
|
DIPHTHERIA + TETANUS + PERTUSSIS + POLIO
|
Facility
OP
|
$103.00
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
41645057
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.05 |
| Max. Negotiated Rate |
$105.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$56.65
|
| 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 |
$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
|
|
|
DIPHTHERIA + TETANUS + PERTUSSIS + POLIO
|
Facility
IP
|
$103.00
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
41645057
|
|
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
|
|
|
DIPHTHERIA + TETANUS TOXOID INJ PEDIATRI
|
Facility
IP
|
$61.00
|
|
| Hospital Charge Code |
41653708
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.50 |
| Max. Negotiated Rate |
$30.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$30.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.50
|
|
|
DIPHTHERIA + TETANUS TOXOID INJ PEDIATRI
|
Facility
OP
|
$61.00
|
|
| Hospital Charge Code |
41653708
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.35 |
| Max. Negotiated Rate |
$39.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$33.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.50
|
| Rate for Payer: Aetna Government |
$30.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$30.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$35.08
|
| Rate for Payer: Group Health Inc Commercial |
$30.50
|
| Rate for Payer: Group Health Inc Medicare |
$21.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$30.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$39.65
|
|
|
DIPHTHERIA + TETANUS TOXOID INJ PEDIATRI
|
Facility
OP
|
$61.00
|
|
| Hospital Charge Code |
41643708
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.35 |
| Max. Negotiated Rate |
$39.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$33.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.50
|
| Rate for Payer: Aetna Government |
$30.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$30.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$35.08
|
| Rate for Payer: Group Health Inc Commercial |
$30.50
|
| Rate for Payer: Group Health Inc Medicare |
$21.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$30.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$39.65
|
|
|
DIPHTHERIA + TETANUS TOXOID INJ PEDIATRI
|
Facility
IP
|
$61.00
|
|
| Hospital Charge Code |
41643708
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.50 |
| Max. Negotiated Rate |
$30.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$30.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.50
|
|
|
DIPHTHERIA + TETANUS TOXOID INJ SYR ADUL
|
Facility
IP
|
$34.00
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
41643864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.00
|
|
|
DIPHTHERIA + TETANUS TOXOID INJ SYR ADUL
|
Facility
IP
|
$34.00
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
41653864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.00
|
|
