|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH [27862]
|
Facility
|
OP
|
$2.12
|
|
|
Service Code
|
NDC 46122-352-74
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.27
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH [27863]
|
Facility
|
OP
|
$2.12
|
|
|
Service Code
|
NDC 46122-353-74
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.27
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH [27863]
|
Facility
|
OP
|
$2.12
|
|
|
Service Code
|
NDC 8770142790
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.27
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH [27863]
|
Facility
|
IP
|
$2.12
|
|
|
Service Code
|
NDC 8770142790
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH [27863]
|
Facility
|
IP
|
$2.06
|
|
|
Service Code
|
NDC 60505-70630
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH [27863]
|
Facility
|
IP
|
$2.22
|
|
|
Service Code
|
NDC 60505-7063-0
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: Multiplan Commercial |
$1.67
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH [27863]
|
Facility
|
OP
|
$2.22
|
|
|
Service Code
|
NDC 60505-7063-0
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.33
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.33
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: Multiplan Commercial |
$1.67
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH [27863]
|
Facility
|
OP
|
$2.06
|
|
|
Service Code
|
NDC 60505-70630
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.24
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH [27863]
|
Facility
|
IP
|
$2.12
|
|
|
Service Code
|
NDC 46122-353-74
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 0363-0196-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.65
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
IP
|
$2.06
|
|
|
Service Code
|
NDC 43598-446-71
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
IP
|
$2.13
|
|
|
Service Code
|
NDC 43598-446-74
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
NDC 43598-446-74
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.28
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
IP
|
$2.22
|
|
|
Service Code
|
NDC 60505-7088-0
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: Multiplan Commercial |
$1.67
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
IP
|
$2.13
|
|
|
Service Code
|
NDC 4898500155
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
NDC 4898500155
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.28
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
OP
|
$2.06
|
|
|
Service Code
|
NDC 0536-5894-88
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.24
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
IP
|
$2.06
|
|
|
Service Code
|
NDC 0536-5894-88
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
OP
|
$2.06
|
|
|
Service Code
|
NDC 0536-1106-88
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.24
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
IP
|
$2.22
|
|
|
Service Code
|
NDC 60505-7061-0
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: Multiplan Commercial |
$1.67
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
IP
|
$2.06
|
|
|
Service Code
|
NDC 0536-1106-88
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
OP
|
$2.06
|
|
|
Service Code
|
NDC 43598-446-71
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.24
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
OP
|
$2.22
|
|
|
Service Code
|
NDC 60505-7088-0
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.33
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.33
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: Multiplan Commercial |
$1.67
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 0363-0196-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.80
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.65
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
OP
|
$2.22
|
|
|
Service Code
|
NDC 60505-7061-0
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.33
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.33
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: Multiplan Commercial |
$1.67
|
|
