St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN [2508]

Facility

$1.92

Service Code	HCPCS J1200
Hospital Charge Code	72485010125
Hospital Revenue Code	250
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$1.54
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.06
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.98
Rate for Payer: Aetna Government	$0.98
Rate for Payer: Brighton Health Commercial	$1.44
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.54
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.31
Rate for Payer: Group Health Inc Commercial	$0.96
Rate for Payer: Group Health Inc Medicare	$0.67
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.96
Rate for Payer: Hamaspik Choice Inc Medicare	$0.96
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.82
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.87
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.87
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.87
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.25

DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN [2508]

Facility

$3.60

Service Code	HCPCS J1200
Hospital Charge Code	72485010105
Hospital Revenue Code	250
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$2.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.98
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.98
Rate for Payer: Aetna Government	$0.98
Rate for Payer: Brighton Health Commercial	$2.70
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.45
Rate for Payer: Group Health Inc Commercial	$1.80
Rate for Payer: Group Health Inc Medicare	$1.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.80
Rate for Payer: Hamaspik Choice Inc Medicare	$1.80
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.82
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.87
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.87
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.87
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.34

DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN [2508]

Facility

$1.41

Service Code	HCPCS J1200
Hospital Charge Code	00641037625
Hospital Revenue Code	250
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$1.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.77
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.98
Rate for Payer: Aetna Government	$0.98
Rate for Payer: Brighton Health Commercial	$1.05
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.96
Rate for Payer: Group Health Inc Commercial	$0.70
Rate for Payer: Group Health Inc Medicare	$0.49
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.70
Rate for Payer: Hamaspik Choice Inc Medicare	$0.70
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.82
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.87
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.87
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.87
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.91

DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN [2508]

Facility

$0.98

Service Code	HCPCS J1200
Hospital Charge Code	72485010101
Hospital Revenue Code	250
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.98
Rate for Payer: Aetna Government	$0.98
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.82
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.87
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.87
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.87

DIPHENHYDRAMINE HCL 50 MG PO CAPS [2510]

Facility

$0.02

Service Code	HCPCS Q0163
Hospital Charge Code	00904530780
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$0.02
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.02
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	$0.01
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

DIPHENHYDRAMINE HCL 50 MG PO CAPS [2510]

Facility

$0.06

Service Code	HCPCS Q0163
Hospital Charge Code	00904205661
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$0.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.04
Rate for Payer: Group Health Inc Commercial	$0.03
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.03
Rate for Payer: Hamaspik Choice Inc Medicare	$0.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.04

DIPHENHYDRAMINE HCL 50 MG PO TABS [2514]

Facility

$0.32

Service Code	NDC 00045023524
Hospital Charge Code	00045023524
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.18
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.16
Rate for Payer: Aetna Government	$0.16
Rate for Payer: Brighton Health Commercial	$0.24
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.22
Rate for Payer: Group Health Inc Commercial	$0.16
Rate for Payer: Group Health Inc Medicare	$0.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.16
Rate for Payer: Hamaspik Choice Inc Medicare	$0.16
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.21

DIPHENHYDRAMINE HCL CHILDRENS 12.5 MG/5ML PO LIQD [165021]

Facility

$0.03

Service Code	NDC 00045053402
Hospital Charge Code	00045053402
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$0.02
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.02
Rate for Payer: Group Health Inc Commercial	$0.01
Rate for Payer: Group Health Inc Medicare	$0.01
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	$0.02

DIPHENHYDRAMINE + MAALOX (1

Facility

$3.00

Hospital Charge Code	41654736
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$2.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.50
Rate for Payer: Aetna Government	$1.50
Rate for Payer: Brighton Health Commercial	$2.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.04
Rate for Payer: Group Health Inc Commercial	$1.50
Rate for Payer: Group Health Inc Medicare	$1.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.95

DIPHENHYDRAMINE + MAALOX (1

Facility

$3.00

Hospital Charge Code	41644736
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$2.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.50
Rate for Payer: Aetna Government	$1.50
Rate for Payer: Brighton Health Commercial	$2.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.04
Rate for Payer: Group Health Inc Commercial	$1.50
Rate for Payer: Group Health Inc Medicare	$1.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.95

DIPHENHYDRAMINE/MAALOX MOUTHWASH (1:1) - COMPOUNDED [700468]

Facility

$0.20

Service Code	NDC 09999123401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.10
Rate for Payer: Aetna Government	$0.10
Rate for Payer: Brighton Health Commercial	$0.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.14
Rate for Payer: Group Health Inc Commercial	$0.10
Rate for Payer: Group Health Inc Medicare	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.10
Rate for Payer: Hamaspik Choice Inc Medicare	$0.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.13

DIPHENHYDRAMINE + MYLANTA + LIDOCAINE LI

Facility

$15.00

Hospital Charge Code	41654739
Hospital Revenue Code	250
Min. Negotiated Rate	$5.25
Max. Negotiated Rate	$12.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.50
Rate for Payer: Aetna Government	$7.50
Rate for Payer: Brighton Health Commercial	$11.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.20
Rate for Payer: Group Health Inc Commercial	$7.50
Rate for Payer: Group Health Inc Medicare	$5.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.50
Rate for Payer: Hamaspik Choice Inc Medicare	$7.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.75

DIPHENHYDRAMINE + MYLANTA + LIDOCAINE LI

Facility

$15.00

Hospital Charge Code	41644739
Hospital Revenue Code	250
Min. Negotiated Rate	$5.25
Max. Negotiated Rate	$12.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.50
Rate for Payer: Aetna Government	$7.50
Rate for Payer: Brighton Health Commercial	$11.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.20
Rate for Payer: Group Health Inc Commercial	$7.50
Rate for Payer: Group Health Inc Medicare	$5.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.50
Rate for Payer: Hamaspik Choice Inc Medicare	$7.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.75

DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABS [2516]

Facility

$0.70

Service Code	NDC 62559049001
Hospital Charge Code	62559049001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.39
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.35
Rate for Payer: Aetna Government	$0.35
Rate for Payer: Brighton Health Commercial	$0.53
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.48
Rate for Payer: Group Health Inc Commercial	$0.35
Rate for Payer: Group Health Inc Medicare	$0.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.35
Rate for Payer: Hamaspik Choice Inc Medicare	$0.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.46

DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABS [2516]

Facility

$0.88

Service Code	NDC 00378041501
Hospital Charge Code	00378041501
Hospital Revenue Code	250
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.44
Rate for Payer: Aetna Government	$0.44
Rate for Payer: Brighton Health Commercial	$0.66
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.60
Rate for Payer: Group Health Inc Commercial	$0.44
Rate for Payer: Group Health Inc Medicare	$0.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.44
Rate for Payer: Hamaspik Choice Inc Medicare	$0.44
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.57

DIPHENOXYLATE + ATROPINE 2.5 MG-0.025 MG

Facility

$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: Brighton Health Commercial	$0.75
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

$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: Brighton Health Commercial	$0.75
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

$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: Brighton Health Commercial	$9.00
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

DIPHENOXYLATE + ATROPINE 2.5 MG-0.025 MG

Facility

$12.00

Hospital Charge Code	41650800
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: Brighton Health Commercial	$9.00
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

$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: Brighton Health Commercial	$61.80
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

$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: Brighton Health Commercial	$61.80
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

$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

$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

$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

$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: Brighton Health Commercial	$0.01
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

Know your out-of-pocket cost for care.

All Charges