|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
OP
|
$120.69
|
|
|
Service Code
|
NDC 60505708900
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.28 |
| Max. Negotiated Rate |
$120.69 |
| Rate for Payer: Aetna Commercial |
$108.62
|
| Rate for Payer: Aetna Medicare |
$60.34
|
| Rate for Payer: ASR ASR |
$117.07
|
| Rate for Payer: ASR Commercial |
$117.07
|
| Rate for Payer: BCBS Complete |
$48.28
|
| Rate for Payer: BCBS Trust/PPO |
$98.83
|
| Rate for Payer: BCN Commercial |
$93.57
|
| Rate for Payer: Cash Price |
$96.55
|
| Rate for Payer: Cofinity Commercial |
$113.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.55
|
| Rate for Payer: Healthscope Commercial |
$120.69
|
| Rate for Payer: Healthscope Whirlpool |
$117.07
|
| Rate for Payer: Mclaren Commercial |
$108.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.59
|
| Rate for Payer: Nomi Health Commercial |
$98.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.45
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$105.75
|
| Rate for Payer: Priority Health Narrow Network |
$84.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$106.21
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$120.69
|
|
|
Service Code
|
NDC 60505708900
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.45 |
| Max. Negotiated Rate |
$120.69 |
| Rate for Payer: Aetna Commercial |
$108.62
|
| Rate for Payer: ASR ASR |
$117.07
|
| Rate for Payer: ASR Commercial |
$117.07
|
| Rate for Payer: BCBS Trust/PPO |
$98.35
|
| Rate for Payer: BCN Commercial |
$93.57
|
| Rate for Payer: Cash Price |
$96.55
|
| Rate for Payer: Cofinity Commercial |
$113.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.55
|
| Rate for Payer: Healthscope Commercial |
$120.69
|
| Rate for Payer: Healthscope Whirlpool |
$117.07
|
| Rate for Payer: Mclaren Commercial |
$108.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.59
|
| Rate for Payer: Nomi Health Commercial |
$98.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$106.21
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
OP
|
$106.98
|
|
|
Service Code
|
NDC 00536589588
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.79 |
| Max. Negotiated Rate |
$106.98 |
| Rate for Payer: Aetna Commercial |
$96.28
|
| Rate for Payer: Aetna Medicare |
$53.49
|
| Rate for Payer: ASR ASR |
$103.77
|
| Rate for Payer: ASR Commercial |
$103.77
|
| Rate for Payer: BCBS Complete |
$42.79
|
| Rate for Payer: BCBS Trust/PPO |
$87.61
|
| Rate for Payer: BCN Commercial |
$82.94
|
| Rate for Payer: Cash Price |
$85.59
|
| Rate for Payer: Cofinity Commercial |
$100.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.58
|
| Rate for Payer: Healthscope Commercial |
$106.98
|
| Rate for Payer: Healthscope Whirlpool |
$103.77
|
| Rate for Payer: Mclaren Commercial |
$96.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$90.93
|
| Rate for Payer: Nomi Health Commercial |
$87.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$93.74
|
| Rate for Payer: Priority Health Narrow Network |
$74.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$94.14
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
OP
|
$58.70
|
|
|
Service Code
|
NDC 00536589553
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.48 |
| Max. Negotiated Rate |
$58.70 |
| Rate for Payer: Aetna Commercial |
$52.83
|
| Rate for Payer: Aetna Medicare |
$29.35
|
| Rate for Payer: ASR ASR |
$56.94
|
| Rate for Payer: ASR Commercial |
$56.94
|
| Rate for Payer: BCBS Complete |
$23.48
|
| Rate for Payer: BCBS Trust/PPO |
$48.07
|
| Rate for Payer: BCN Commercial |
$45.51
|
| Rate for Payer: Cash Price |
$46.96
|
| Rate for Payer: Cofinity Commercial |
$55.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.96
|
| Rate for Payer: Healthscope Commercial |
$58.70
|
| Rate for Payer: Healthscope Whirlpool |
$56.94
|
| Rate for Payer: Mclaren Commercial |
$52.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.90
|
| Rate for Payer: Nomi Health Commercial |
$48.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$51.43
|
| Rate for Payer: Priority Health Narrow Network |
$41.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$51.66
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
OP
|
$62.30
|
|
|
Service Code
|
NDC 43598044770
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.92 |
| Max. Negotiated Rate |
$62.30 |
| Rate for Payer: Aetna Commercial |
$56.07
|
| Rate for Payer: Aetna Medicare |
$31.15
|
| Rate for Payer: ASR ASR |
$60.43
|
| Rate for Payer: ASR Commercial |
$60.43
|
| Rate for Payer: BCBS Complete |
$24.92
|
| Rate for Payer: BCBS Trust/PPO |
$51.02
|
| Rate for Payer: BCN Commercial |
$48.30
|
| Rate for Payer: Cash Price |
$49.84
|
| Rate for Payer: Cofinity Commercial |
$58.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.84
|
| Rate for Payer: Healthscope Commercial |
$62.30
|
| Rate for Payer: Healthscope Whirlpool |
$60.43
|
| Rate for Payer: Mclaren Commercial |
$56.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.96
|
| Rate for Payer: Nomi Health Commercial |
$51.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$54.59
|
| Rate for Payer: Priority Health Narrow Network |
$43.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$54.82
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$62.30
|
|
|
Service Code
|
NDC 43598044770
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.50 |
| Max. Negotiated Rate |
$62.30 |
| Rate for Payer: Aetna Commercial |
$56.07
|
| Rate for Payer: ASR ASR |
$60.43
|
| Rate for Payer: ASR Commercial |
$60.43
|
| Rate for Payer: BCBS Trust/PPO |
$50.77
|
| Rate for Payer: BCN Commercial |
$48.30
|
| Rate for Payer: Cash Price |
$49.84
|
| Rate for Payer: Cofinity Commercial |
$58.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.84
|
| Rate for Payer: Healthscope Commercial |
$62.30
|
| Rate for Payer: Healthscope Whirlpool |
$60.43
|
| Rate for Payer: Mclaren Commercial |
$56.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.96
|
| Rate for Payer: Nomi Health Commercial |
$51.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$54.82
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$106.98
|
|
|
Service Code
|
NDC 00536589588
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.54 |
| Max. Negotiated Rate |
$106.98 |
| Rate for Payer: Aetna Commercial |
$96.28
|
| Rate for Payer: ASR ASR |
$103.77
|
| Rate for Payer: ASR Commercial |
$103.77
|
| Rate for Payer: BCBS Trust/PPO |
$87.18
|
| Rate for Payer: BCN Commercial |
$82.94
|
| Rate for Payer: Cash Price |
$85.59
|
| Rate for Payer: Cofinity Commercial |
$100.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.58
|
| Rate for Payer: Healthscope Commercial |
$106.98
|
| Rate for Payer: Healthscope Whirlpool |
$103.77
|
| Rate for Payer: Mclaren Commercial |
$96.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$90.93
|
| Rate for Payer: Nomi Health Commercial |
$87.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$94.14
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$8.22
|
|
|
Service Code
|
NDC 43598044771
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.34 |
| Max. Negotiated Rate |
$8.22 |
| Rate for Payer: Aetna Commercial |
$7.40
|
| Rate for Payer: ASR ASR |
$7.97
|
| Rate for Payer: ASR Commercial |
$7.97
|
| Rate for Payer: BCBS Trust/PPO |
$6.70
|
| Rate for Payer: BCN Commercial |
$6.37
|
| Rate for Payer: Cash Price |
$6.58
|
| Rate for Payer: Cofinity Commercial |
$7.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.58
|
| Rate for Payer: Healthscope Commercial |
$8.22
|
| Rate for Payer: Healthscope Whirlpool |
$7.97
|
| Rate for Payer: Mclaren Commercial |
$7.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.99
|
| Rate for Payer: Nomi Health Commercial |
$6.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7.23
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$8.62
|
|
|
Service Code
|
NDC 60505706200
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.62 |
| Rate for Payer: Aetna Commercial |
$7.76
|
| Rate for Payer: ASR ASR |
$8.36
|
| Rate for Payer: ASR Commercial |
$8.36
|
| Rate for Payer: BCBS Trust/PPO |
$7.02
|
| Rate for Payer: BCN Commercial |
$6.68
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cofinity Commercial |
$8.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.90
|
| Rate for Payer: Healthscope Commercial |
$8.62
|
| Rate for Payer: Healthscope Whirlpool |
$8.36
|
| Rate for Payer: Mclaren Commercial |
$7.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.33
|
| Rate for Payer: Nomi Health Commercial |
$7.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7.59
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$58.70
|
|
|
Service Code
|
NDC 00536589553
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.16 |
| Max. Negotiated Rate |
$58.70 |
| Rate for Payer: Aetna Commercial |
$52.83
|
| Rate for Payer: ASR ASR |
$56.94
|
| Rate for Payer: ASR Commercial |
$56.94
|
| Rate for Payer: BCBS Trust/PPO |
$47.83
|
| Rate for Payer: BCN Commercial |
$45.51
|
| Rate for Payer: Cash Price |
$46.96
|
| Rate for Payer: Cofinity Commercial |
$55.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.96
|
| Rate for Payer: Healthscope Commercial |
$58.70
|
| Rate for Payer: Healthscope Whirlpool |
$56.94
|
| Rate for Payer: Mclaren Commercial |
$52.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.90
|
| Rate for Payer: Nomi Health Commercial |
$48.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$51.66
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$174.77
|
|
|
Service Code
|
NDC 00766143020
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.60 |
| Max. Negotiated Rate |
$174.77 |
| Rate for Payer: Aetna Commercial |
$157.29
|
| Rate for Payer: ASR ASR |
$169.53
|
| Rate for Payer: ASR Commercial |
$169.53
|
| Rate for Payer: BCBS Trust/PPO |
$142.42
|
| Rate for Payer: BCN Commercial |
$135.50
|
| Rate for Payer: Cash Price |
$139.82
|
| Rate for Payer: Cofinity Commercial |
$164.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$139.82
|
| Rate for Payer: Healthscope Commercial |
$174.77
|
| Rate for Payer: Healthscope Whirlpool |
$169.53
|
| Rate for Payer: Mclaren Commercial |
$157.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$148.55
|
| Rate for Payer: Nomi Health Commercial |
$143.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$153.80
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
OP
|
$8.62
|
|
|
Service Code
|
NDC 60505706200
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.45 |
| Max. Negotiated Rate |
$8.62 |
| Rate for Payer: Aetna Commercial |
$7.76
|
| Rate for Payer: Aetna Medicare |
$4.31
|
| Rate for Payer: ASR ASR |
$8.36
|
| Rate for Payer: ASR Commercial |
$8.36
|
| Rate for Payer: BCBS Complete |
$3.45
|
| Rate for Payer: BCBS Trust/PPO |
$7.06
|
| Rate for Payer: BCN Commercial |
$6.68
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cofinity Commercial |
$8.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.90
|
| Rate for Payer: Healthscope Commercial |
$8.62
|
| Rate for Payer: Healthscope Whirlpool |
$8.36
|
| Rate for Payer: Mclaren Commercial |
$7.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.33
|
| Rate for Payer: Nomi Health Commercial |
$7.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7.55
|
| Rate for Payer: Priority Health Narrow Network |
$6.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7.59
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
OP
|
$8.22
|
|
|
Service Code
|
NDC 43598044771
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.29 |
| Max. Negotiated Rate |
$8.22 |
| Rate for Payer: Aetna Commercial |
$7.40
|
| Rate for Payer: Aetna Medicare |
$4.11
|
| Rate for Payer: ASR ASR |
$7.97
|
| Rate for Payer: ASR Commercial |
$7.97
|
| Rate for Payer: BCBS Complete |
$3.29
|
| Rate for Payer: BCBS Trust/PPO |
$6.73
|
| Rate for Payer: BCN Commercial |
$6.37
|
| Rate for Payer: Cash Price |
$6.58
|
| Rate for Payer: Cofinity Commercial |
$7.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.58
|
| Rate for Payer: Healthscope Commercial |
$8.22
|
| Rate for Payer: Healthscope Whirlpool |
$7.97
|
| Rate for Payer: Mclaren Commercial |
$7.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.99
|
| Rate for Payer: Nomi Health Commercial |
$6.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7.20
|
| Rate for Payer: Priority Health Narrow Network |
$5.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7.23
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
OP
|
$174.77
|
|
|
Service Code
|
NDC 00766143020
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.91 |
| Max. Negotiated Rate |
$174.77 |
| Rate for Payer: Aetna Commercial |
$157.29
|
| Rate for Payer: Aetna Medicare |
$87.38
|
| Rate for Payer: ASR ASR |
$169.53
|
| Rate for Payer: ASR Commercial |
$169.53
|
| Rate for Payer: BCBS Complete |
$69.91
|
| Rate for Payer: BCBS Trust/PPO |
$143.12
|
| Rate for Payer: BCN Commercial |
$135.50
|
| Rate for Payer: Cash Price |
$139.82
|
| Rate for Payer: Cofinity Commercial |
$164.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$139.82
|
| Rate for Payer: Healthscope Commercial |
$174.77
|
| Rate for Payer: Healthscope Whirlpool |
$169.53
|
| Rate for Payer: Mclaren Commercial |
$157.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$148.55
|
| Rate for Payer: Nomi Health Commercial |
$143.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$153.13
|
| Rate for Payer: Priority Health Narrow Network |
$122.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$153.80
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
OP
|
$95.09
|
|
|
Service Code
|
NDC 00536589688
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.04 |
| Max. Negotiated Rate |
$95.09 |
| Rate for Payer: Aetna Commercial |
$85.58
|
| Rate for Payer: Aetna Medicare |
$47.54
|
| Rate for Payer: ASR ASR |
$92.24
|
| Rate for Payer: ASR Commercial |
$92.24
|
| Rate for Payer: BCBS Complete |
$38.04
|
| Rate for Payer: BCBS Trust/PPO |
$77.87
|
| Rate for Payer: BCN Commercial |
$73.72
|
| Rate for Payer: Cash Price |
$76.07
|
| Rate for Payer: Cofinity Commercial |
$89.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.07
|
| Rate for Payer: Healthscope Commercial |
$95.09
|
| Rate for Payer: Healthscope Whirlpool |
$92.24
|
| Rate for Payer: Mclaren Commercial |
$85.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.83
|
| Rate for Payer: Nomi Health Commercial |
$77.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$83.32
|
| Rate for Payer: Priority Health Narrow Network |
$66.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$83.68
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
OP
|
$115.11
|
|
|
Service Code
|
NDC 00536110888
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.04 |
| Max. Negotiated Rate |
$115.11 |
| Rate for Payer: Aetna Commercial |
$103.60
|
| Rate for Payer: Aetna Medicare |
$57.56
|
| Rate for Payer: ASR ASR |
$111.66
|
| Rate for Payer: ASR Commercial |
$111.66
|
| Rate for Payer: BCBS Complete |
$46.04
|
| Rate for Payer: BCBS Trust/PPO |
$94.26
|
| Rate for Payer: BCN Commercial |
$89.24
|
| Rate for Payer: Cash Price |
$92.09
|
| Rate for Payer: Cofinity Commercial |
$108.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.09
|
| Rate for Payer: Healthscope Commercial |
$115.11
|
| Rate for Payer: Healthscope Whirlpool |
$111.66
|
| Rate for Payer: Mclaren Commercial |
$103.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$97.84
|
| Rate for Payer: Nomi Health Commercial |
$94.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.82
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$100.86
|
| Rate for Payer: Priority Health Narrow Network |
$80.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$101.30
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$115.11
|
|
|
Service Code
|
NDC 00536110888
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.82 |
| Max. Negotiated Rate |
$115.11 |
| Rate for Payer: Aetna Commercial |
$103.60
|
| Rate for Payer: ASR ASR |
$111.66
|
| Rate for Payer: ASR Commercial |
$111.66
|
| Rate for Payer: BCBS Trust/PPO |
$93.80
|
| Rate for Payer: BCN Commercial |
$89.24
|
| Rate for Payer: Cash Price |
$92.09
|
| Rate for Payer: Cofinity Commercial |
$108.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.09
|
| Rate for Payer: Healthscope Commercial |
$115.11
|
| Rate for Payer: Healthscope Whirlpool |
$111.66
|
| Rate for Payer: Mclaren Commercial |
$103.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$97.84
|
| Rate for Payer: Nomi Health Commercial |
$94.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$101.30
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$95.09
|
|
|
Service Code
|
NDC 00536589688
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.81 |
| Max. Negotiated Rate |
$95.09 |
| Rate for Payer: Aetna Commercial |
$85.58
|
| Rate for Payer: ASR ASR |
$92.24
|
| Rate for Payer: ASR Commercial |
$92.24
|
| Rate for Payer: BCBS Trust/PPO |
$77.49
|
| Rate for Payer: BCN Commercial |
$73.72
|
| Rate for Payer: Cash Price |
$76.07
|
| Rate for Payer: Cofinity Commercial |
$89.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.07
|
| Rate for Payer: Healthscope Commercial |
$95.09
|
| Rate for Payer: Healthscope Whirlpool |
$92.24
|
| Rate for Payer: Mclaren Commercial |
$85.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.83
|
| Rate for Payer: Nomi Health Commercial |
$77.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$83.68
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL MINI LOZENGE
|
Facility
|
IP
|
$289.33
|
|
|
Service Code
|
NDC 45802008902
|
| Hospital Charge Code |
182298
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.06 |
| Max. Negotiated Rate |
$289.33 |
| Rate for Payer: Aetna Commercial |
$260.40
|
| Rate for Payer: ASR ASR |
$280.65
|
| Rate for Payer: ASR Commercial |
$280.65
|
| Rate for Payer: BCBS Trust/PPO |
$235.78
|
| Rate for Payer: BCN Commercial |
$224.32
|
| Rate for Payer: Cash Price |
$231.47
|
| Rate for Payer: Cofinity Commercial |
$271.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$231.46
|
| Rate for Payer: Healthscope Commercial |
$289.33
|
| Rate for Payer: Healthscope Whirlpool |
$280.65
|
| Rate for Payer: Mclaren Commercial |
$260.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$245.93
|
| Rate for Payer: Nomi Health Commercial |
$237.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$188.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$254.61
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL MINI LOZENGE
|
Facility
|
IP
|
$263.17
|
|
|
Service Code
|
NDC 00536123981
|
| Hospital Charge Code |
182298
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.06 |
| Max. Negotiated Rate |
$263.17 |
| Rate for Payer: Aetna Commercial |
$236.85
|
| Rate for Payer: ASR ASR |
$255.27
|
| Rate for Payer: ASR Commercial |
$255.27
|
| Rate for Payer: BCBS Trust/PPO |
$214.46
|
| Rate for Payer: BCN Commercial |
$204.04
|
| Rate for Payer: Cash Price |
$210.54
|
| Rate for Payer: Cofinity Commercial |
$247.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$210.54
|
| Rate for Payer: Healthscope Commercial |
$263.17
|
| Rate for Payer: Healthscope Whirlpool |
$255.27
|
| Rate for Payer: Mclaren Commercial |
$236.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$223.69
|
| Rate for Payer: Nomi Health Commercial |
$215.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$171.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$231.59
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL MINI LOZENGE
|
Facility
|
OP
|
$263.17
|
|
|
Service Code
|
NDC 00536123981
|
| Hospital Charge Code |
182298
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.27 |
| Max. Negotiated Rate |
$263.17 |
| Rate for Payer: Aetna Commercial |
$236.85
|
| Rate for Payer: Aetna Medicare |
$131.58
|
| Rate for Payer: ASR ASR |
$255.27
|
| Rate for Payer: ASR Commercial |
$255.27
|
| Rate for Payer: BCBS Complete |
$105.27
|
| Rate for Payer: BCBS Trust/PPO |
$215.51
|
| Rate for Payer: BCN Commercial |
$204.04
|
| Rate for Payer: Cash Price |
$210.54
|
| Rate for Payer: Cofinity Commercial |
$247.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$210.54
|
| Rate for Payer: Healthscope Commercial |
$263.17
|
| Rate for Payer: Healthscope Whirlpool |
$255.27
|
| Rate for Payer: Mclaren Commercial |
$236.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$223.69
|
| Rate for Payer: Nomi Health Commercial |
$215.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$171.06
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$230.59
|
| Rate for Payer: Priority Health Narrow Network |
$184.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$231.59
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL MINI LOZENGE
|
Facility
|
OP
|
$289.33
|
|
|
Service Code
|
NDC 45802008902
|
| Hospital Charge Code |
182298
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.73 |
| Max. Negotiated Rate |
$289.33 |
| Rate for Payer: Aetna Commercial |
$260.40
|
| Rate for Payer: Aetna Medicare |
$144.66
|
| Rate for Payer: ASR ASR |
$280.65
|
| Rate for Payer: ASR Commercial |
$280.65
|
| Rate for Payer: BCBS Complete |
$115.73
|
| Rate for Payer: BCBS Trust/PPO |
$236.93
|
| Rate for Payer: BCN Commercial |
$224.32
|
| Rate for Payer: Cash Price |
$231.47
|
| Rate for Payer: Cofinity Commercial |
$271.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$231.46
|
| Rate for Payer: Healthscope Commercial |
$289.33
|
| Rate for Payer: Healthscope Whirlpool |
$280.65
|
| Rate for Payer: Mclaren Commercial |
$260.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$245.93
|
| Rate for Payer: Nomi Health Commercial |
$237.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$188.06
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$253.51
|
| Rate for Payer: Priority Health Narrow Network |
$202.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$254.61
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL MINI LOZENGE
|
Facility
|
OP
|
$96.44
|
|
|
Service Code
|
NDC 45802008901
|
| Hospital Charge Code |
182298
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.58 |
| Max. Negotiated Rate |
$96.44 |
| Rate for Payer: Aetna Commercial |
$86.80
|
| Rate for Payer: Aetna Medicare |
$48.22
|
| Rate for Payer: ASR ASR |
$93.55
|
| Rate for Payer: ASR Commercial |
$93.55
|
| Rate for Payer: BCBS Complete |
$38.58
|
| Rate for Payer: BCBS Trust/PPO |
$78.97
|
| Rate for Payer: BCN Commercial |
$74.77
|
| Rate for Payer: Cash Price |
$77.16
|
| Rate for Payer: Cofinity Commercial |
$90.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.15
|
| Rate for Payer: Healthscope Commercial |
$96.44
|
| Rate for Payer: Healthscope Whirlpool |
$93.55
|
| Rate for Payer: Mclaren Commercial |
$86.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.97
|
| Rate for Payer: Nomi Health Commercial |
$79.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.69
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$84.50
|
| Rate for Payer: Priority Health Narrow Network |
$67.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$84.87
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL MINI LOZENGE
|
Facility
|
OP
|
$60.19
|
|
|
Service Code
|
NDC 07667088057
|
| Hospital Charge Code |
182298
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.08 |
| Max. Negotiated Rate |
$60.19 |
| Rate for Payer: Aetna Commercial |
$54.17
|
| Rate for Payer: Aetna Medicare |
$30.10
|
| Rate for Payer: ASR ASR |
$58.38
|
| Rate for Payer: ASR Commercial |
$58.38
|
| Rate for Payer: BCBS Complete |
$24.08
|
| Rate for Payer: BCBS Trust/PPO |
$49.29
|
| Rate for Payer: BCN Commercial |
$46.67
|
| Rate for Payer: Cash Price |
$48.15
|
| Rate for Payer: Cofinity Commercial |
$56.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.15
|
| Rate for Payer: Healthscope Commercial |
$60.19
|
| Rate for Payer: Healthscope Whirlpool |
$58.38
|
| Rate for Payer: Mclaren Commercial |
$54.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$51.16
|
| Rate for Payer: Nomi Health Commercial |
$49.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.12
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$52.74
|
| Rate for Payer: Priority Health Narrow Network |
$42.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$52.97
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL MINI LOZENGE
|
Facility
|
IP
|
$60.19
|
|
|
Service Code
|
NDC 07667088057
|
| Hospital Charge Code |
182298
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.12 |
| Max. Negotiated Rate |
$60.19 |
| Rate for Payer: Aetna Commercial |
$54.17
|
| Rate for Payer: ASR ASR |
$58.38
|
| Rate for Payer: ASR Commercial |
$58.38
|
| Rate for Payer: BCBS Trust/PPO |
$49.05
|
| Rate for Payer: BCN Commercial |
$46.67
|
| Rate for Payer: Cash Price |
$48.15
|
| Rate for Payer: Cofinity Commercial |
$56.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.15
|
| Rate for Payer: Healthscope Commercial |
$60.19
|
| Rate for Payer: Healthscope Whirlpool |
$58.38
|
| Rate for Payer: Mclaren Commercial |
$54.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$51.16
|
| Rate for Payer: Nomi Health Commercial |
$49.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$52.97
|
|
