Contract Rates for Separately Reimbursable Covered Services. The Contract Rate for the provision of the Covered Services set forth in Table 3 of this Appendix rendered by Facility to a Customer on an inpatient or outpatient basis, will be as set forth in Table 3 of this Appendix. If more than one type of Separately Reimbursable Service Category listed on Table 3 below is provided to a Customer during one calendar day, the applicable contract rate for each Separately Reimbursable Service Category will be considered in calculating the aggregate contract rate. Table 3: Separately Reimbursable Covered Services Category Table SERVICE CATEGORY SERVICE CATEGORY DEFINITION PAYMENT METHOD CONTRACT RATE Annual Vaccination- Influenza Revenue Code 0636 and CPT Codes 90630-90698, 90756, HCPCS Codes Q2034-Q2039 Per Unit 100% of the CMS Fee Schedule Annual Vaccination Administration- Influenza Revenue Code 0771 and HCPCS Code G0008 Per Unit 100% of the CMS Fee Schedule Annual Vaccination- Pneumococcal Revenue Code 0636 and CPT Codes 90670, 90677 or 90732 Per Unit 100% of the CMS Fee Schedule Annual Vaccine Administration- Pneumococcal Revenue Code 0771 and HCPCS Code G0009 Per Unit 100% of the CMS Fee Schedule
