|
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: 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
|
|
|
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
|
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: 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
|
|
|
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: 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
|
|
|
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: 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
|
|
|
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 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
|
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: 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
|
|
|
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: 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
|
|
|
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
|
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 |
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: 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
|
|
|
DIPH/TET/PERT (VFC) 0.5ML SYR
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
41646909
|
|
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 (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: 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
|
|
|
DIPH/TET/PERT (VFC) 0.5ML SYR
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
41656909
|
|
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 (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: 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
|
|
|
DIPH/TET/PERT (VFC) 0.5ML VIAL
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
41647001
|
|
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 (VFC) 0.5ML VIAL
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
41657001
|
|
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: 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
|
|
|
DIPH/TET/PERT (VFC) 0.5ML VIAL
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
41656907
|
|
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: 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
|
|
|
DIPH/TET/PERT (VFC) 0.5ML VIAL
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
41646907
|
|
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: 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
|
|
|
DIPH/TET/PERT (VFC) 0.5ML VIAL
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
41657001
|
|
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 (VFC) 0.5ML VIAL
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
41647001
|
|
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: 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
|
|
|
DIPH/TET/PERT (VFC) 0.5ML VIAL
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
41656907
|
|
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
|
|
