|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH [27862]
|
Facility
|
IP
|
$2.12
|
|
|
Service Code
|
NDC 8770142789
|
| Hospital Charge Code |
1743655
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.59 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH [27862]
|
Facility
|
OP
|
$2.12
|
|
|
Service Code
|
NDC 46122-352-74
|
| Hospital Charge Code |
1743655
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.59
|
| Rate for Payer: Blue Shield of California Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$1.24
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.80
|
| Rate for Payer: Dignity Health Senior |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.85
|
| Rate for Payer: TriValley Medical Group Senior |
$0.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.80
|
| Rate for Payer: Vantage Medical Group Senior |
$1.80
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH [27863]
|
Facility
|
IP
|
$2.12
|
|
|
Service Code
|
NDC 46122-353-74
|
| Hospital Charge Code |
1743656
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.59 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| 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 |
1743656
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.59
|
| Rate for Payer: Blue Shield of California Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$1.24
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.80
|
| Rate for Payer: Dignity Health Senior |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.85
|
| Rate for Payer: TriValley Medical Group Senior |
$0.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.80
|
| Rate for Payer: Vantage Medical Group Senior |
$1.80
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH [27863]
|
Facility
|
IP
|
$2.12
|
|
|
Service Code
|
NDC 8770142790
|
| Hospital Charge Code |
1743656
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.59 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| 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 |
1743656
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.59
|
| Rate for Payer: Blue Shield of California Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$1.24
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.80
|
| Rate for Payer: Dignity Health Senior |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.85
|
| Rate for Payer: TriValley Medical Group Senior |
$0.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.80
|
| Rate for Payer: Vantage Medical Group Senior |
$1.80
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 0363-0196-02
|
| Hospital Charge Code |
1743654
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.03
|
| Rate for Payer: Heritage Provider Network Senior |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
IP
|
$2.06
|
|
|
Service Code
|
NDC 0536-5894-33
|
| Hospital Charge Code |
1743654
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.42
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Senior |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
IP
|
$2.13
|
|
|
Service Code
|
NDC 4898500155
|
| Hospital Charge Code |
1743654
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
IP
|
$2.06
|
|
|
Service Code
|
NDC 0536-1106-88
|
| Hospital Charge Code |
1743654
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.42
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Senior |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
NDC 43598-446-74
|
| Hospital Charge Code |
1743654
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.60
|
| Rate for Payer: Blue Shield of California Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$1.25
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.81
|
| Rate for Payer: Dignity Health Senior |
$1.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Senior |
$1.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.85
|
| Rate for Payer: TriValley Medical Group Senior |
$0.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: Vantage Medical Group Senior |
$1.81
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
IP
|
$2.06
|
|
|
Service Code
|
NDC 43598-446-71
|
| Hospital Charge Code |
1743654
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.42
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Senior |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| 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 |
1743654
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.54
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.21
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.75
|
| Rate for Payer: Dignity Health Senior |
$1.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Senior |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.82
|
| Rate for Payer: TriValley Medical Group Senior |
$0.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.75
|
| Rate for Payer: Vantage Medical Group Senior |
$1.75
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
OP
|
$2.06
|
|
|
Service Code
|
NDC 0536-5894-33
|
| Hospital Charge Code |
1743654
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.54
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.21
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.75
|
| Rate for Payer: Dignity Health Senior |
$1.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Senior |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.82
|
| Rate for Payer: TriValley Medical Group Senior |
$0.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.75
|
| Rate for Payer: Vantage Medical Group Senior |
$1.75
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 0363-0196-02
|
| Hospital Charge Code |
1743654
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.76
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Senior |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Senior |
$1.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
NDC 4898500155
|
| Hospital Charge Code |
1743654
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.60
|
| Rate for Payer: Blue Shield of California Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$1.25
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.81
|
| Rate for Payer: Dignity Health Senior |
$1.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Senior |
$1.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.85
|
| Rate for Payer: TriValley Medical Group Senior |
$0.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: Vantage Medical Group Senior |
$1.81
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
IP
|
$2.13
|
|
|
Service Code
|
NDC 43598-446-74
|
| Hospital Charge Code |
1743654
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
OP
|
$2.06
|
|
|
Service Code
|
NDC 0536-1106-88
|
| Hospital Charge Code |
1743654
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.54
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.21
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.75
|
| Rate for Payer: Dignity Health Senior |
$1.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Senior |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.82
|
| Rate for Payer: TriValley Medical Group Senior |
$0.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.75
|
| Rate for Payer: Vantage Medical Group Senior |
$1.75
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
OP
|
$2.06
|
|
|
Service Code
|
NDC 0536-5894-88
|
| Hospital Charge Code |
1743654
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.54
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.21
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.75
|
| Rate for Payer: Dignity Health Senior |
$1.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Senior |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.82
|
| Rate for Payer: TriValley Medical Group Senior |
$0.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.75
|
| Rate for Payer: Vantage Medical Group Senior |
$1.75
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]
|
Facility
|
IP
|
$2.06
|
|
|
Service Code
|
NDC 0536-5894-88
|
| Hospital Charge Code |
1743654
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.42
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Senior |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL LOZENGE [34769]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 45802-344-05
|
| Hospital Charge Code |
1712388
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL LOZENGE [34769]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 46122-734-62
|
| Hospital Charge Code |
1712388
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL LOZENGE [34769]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 46122-734-08
|
| Hospital Charge Code |
1712388
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: Dignity Health Senior |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL LOZENGE [34769]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 45802-344-05
|
| Hospital Charge Code |
1712388
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.40
|
| Rate for Payer: Dignity Health Senior |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Senior |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL LOZENGE [34769]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 45802-344-03
|
| Hospital Charge Code |
1712388
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
