|
NICOTINE 14 MG/24HR TD PT24
|
Facility
|
IP
|
$2.52
|
|
|
Service Code
|
NDC 4359844770
|
| Hospital Charge Code |
4359844770
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.26
|
|
|
NICOTINE 14 MG/24HR TD PT24
|
Facility
|
OP
|
$2.52
|
|
|
Service Code
|
NDC 4359844770
|
| Hospital Charge Code |
4359844770
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.39
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.26
|
| Rate for Payer: Aetna Government |
$1.26
|
| Rate for Payer: Brighton Health Commercial |
$1.89
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.71
|
| Rate for Payer: EmblemHealth Commercial |
$1.26
|
| Rate for Payer: Group Health Inc Commercial |
$1.26
|
| Rate for Payer: Group Health Inc Medicare |
$0.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.64
|
|
|
NICOTINE 14 MG/24HR TD PT24
|
Facility
|
OP
|
$2.29
|
|
|
Service Code
|
NDC 6050570620
|
| Hospital Charge Code |
6050570620
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.83 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.26
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.14
|
| Rate for Payer: Aetna Government |
$1.14
|
| Rate for Payer: Brighton Health Commercial |
$1.71
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.83
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.55
|
| Rate for Payer: EmblemHealth Commercial |
$1.14
|
| Rate for Payer: Group Health Inc Commercial |
$1.14
|
| Rate for Payer: Group Health Inc Medicare |
$0.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.49
|
|
|
NICOTINE 21 MG/24HR TD PT24
|
Facility
|
IP
|
$2.57
|
|
|
Service Code
|
NDC 6050570630
|
| Hospital Charge Code |
6050570630
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.29
|
|
|
NICOTINE 21 MG/24HR TD PT24
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
NDC 4359844874
|
| Hospital Charge Code |
4359844874
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.07
|
| Rate for Payer: Aetna Government |
$1.07
|
| Rate for Payer: Brighton Health Commercial |
$1.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.71
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.45
|
| Rate for Payer: EmblemHealth Commercial |
$1.07
|
| Rate for Payer: Group Health Inc Commercial |
$1.07
|
| Rate for Payer: Group Health Inc Medicare |
$0.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.07
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.39
|
|
|
NICOTINE 21 MG/24HR TD PT24
|
Facility
|
IP
|
$2.13
|
|
|
Service Code
|
NDC 4359844874
|
| Hospital Charge Code |
4359844874
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.07
|
|
|
NICOTINE 21 MG/24HR TD PT24
|
Facility
|
OP
|
$2.14
|
|
|
Service Code
|
NDC 0536589688
|
| Hospital Charge Code |
0536589688
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.07
|
| Rate for Payer: Aetna Government |
$1.07
|
| Rate for Payer: Brighton Health Commercial |
$1.61
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.71
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.46
|
| Rate for Payer: EmblemHealth Commercial |
$1.07
|
| Rate for Payer: Group Health Inc Commercial |
$1.07
|
| Rate for Payer: Group Health Inc Medicare |
$0.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.07
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.39
|
|
|
NICOTINE 21 MG/24HR TD PT24
|
Facility
|
IP
|
$2.14
|
|
|
Service Code
|
NDC 0536589688
|
| Hospital Charge Code |
0536589688
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.07
|
|
|
NICOTINE 21 MG/24HR TD PT24
|
Facility
|
OP
|
$2.14
|
|
|
Service Code
|
NDC 0536110888
|
| Hospital Charge Code |
0536110888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.07
|
| Rate for Payer: Aetna Government |
$1.07
|
| Rate for Payer: Brighton Health Commercial |
$1.61
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.71
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.46
|
| Rate for Payer: EmblemHealth Commercial |
$1.07
|
| Rate for Payer: Group Health Inc Commercial |
$1.07
|
| Rate for Payer: Group Health Inc Medicare |
$0.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.07
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.39
|
|
|
NICOTINE 21 MG/24HR TD PT24
|
Facility
|
IP
|
$2.14
|
|
|
Service Code
|
NDC 0536110888
|
| Hospital Charge Code |
0536110888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.07
|
|
|
NICOTINE 21 MG/24HR TD PT24
|
Facility
|
IP
|
$1.92
|
|
|
Service Code
|
NDC 4359844828
|
| Hospital Charge Code |
4359844828
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.96
|
|
|
NICOTINE 21 MG/24HR TD PT24
|
Facility
|
OP
|
$1.92
|
|
|
Service Code
|
NDC 4359844828
|
| Hospital Charge Code |
4359844828
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.96
|
| Rate for Payer: Aetna Government |
$0.96
|
| Rate for Payer: Brighton Health Commercial |
$1.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.54
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.31
|
| Rate for Payer: EmblemHealth Commercial |
$0.96
|
| Rate for Payer: Group Health Inc Commercial |
$0.96
|
| Rate for Payer: Group Health Inc Medicare |
$0.67
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.25
|
|
|
NICOTINE 21 MG/24HR TD PT24
|
Facility
|
OP
|
$2.57
|
|
|
Service Code
|
NDC 6050570630
|
| Hospital Charge Code |
6050570630
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.41
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.29
|
| Rate for Payer: Aetna Government |
$1.29
|
| Rate for Payer: Brighton Health Commercial |
$1.93
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.75
|
| Rate for Payer: EmblemHealth Commercial |
$1.29
|
| Rate for Payer: Group Health Inc Commercial |
$1.29
|
| Rate for Payer: Group Health Inc Medicare |
$0.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.67
|
|
|
NICOTINE POLACRILEX 2 MG MT GUM
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 0536136223
|
| Hospital Charge Code |
0536136223
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.14
|
| Rate for Payer: Aetna Government |
$0.14
|
| Rate for Payer: Brighton Health Commercial |
$0.21
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.23
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.19
|
| Rate for Payer: EmblemHealth Commercial |
$0.14
|
| Rate for Payer: Group Health Inc Commercial |
$0.14
|
| Rate for Payer: Group Health Inc Medicare |
$0.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.18
|
|
|
NICOTINE POLACRILEX 2 MG MT GUM
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 0536136223
|
| Hospital Charge Code |
0536136223
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.14
|
|
|
NICOTINE POLACRILEX 2 MG MT GUM
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 0536136206
|
| Hospital Charge Code |
0536136206
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.23
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.21
|
| Rate for Payer: Aetna Government |
$0.21
|
| Rate for Payer: Brighton Health Commercial |
$0.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.29
|
| Rate for Payer: EmblemHealth Commercial |
$0.21
|
| Rate for Payer: Group Health Inc Commercial |
$0.21
|
| Rate for Payer: Group Health Inc Medicare |
$0.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.21
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.28
|
|
|
NICOTINE POLACRILEX 2 MG MT GUM
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 0536136206
|
| Hospital Charge Code |
0536136206
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.21
|
|
|
NICOTINE POLACRILEX 2 MG MT GUM
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 0536302934
|
| Hospital Charge Code |
0536302934
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.33
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.30
|
| Rate for Payer: Aetna Government |
$0.30
|
| Rate for Payer: Brighton Health Commercial |
$0.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.48
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.41
|
| Rate for Payer: EmblemHealth Commercial |
$0.30
|
| Rate for Payer: Group Health Inc Commercial |
$0.30
|
| Rate for Payer: Group Health Inc Medicare |
$0.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.39
|
|
|
NICOTINE POLACRILEX 2 MG MT GUM
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 0536302934
|
| Hospital Charge Code |
0536302934
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.30
|
|
|
NICOTINE POLACRILEX 2 MG MT GUM
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 0536302923
|
| Hospital Charge Code |
0536302923
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.14
|
| Rate for Payer: Aetna Government |
$0.14
|
| Rate for Payer: Brighton Health Commercial |
$0.21
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.23
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.19
|
| Rate for Payer: EmblemHealth Commercial |
$0.14
|
| Rate for Payer: Group Health Inc Commercial |
$0.14
|
| Rate for Payer: Group Health Inc Medicare |
$0.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.18
|
|
|
NICOTINE POLACRILEX 2 MG MT GUM
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 0536302923
|
| Hospital Charge Code |
0536302923
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.14
|
|
|
NICOTINE POLACRILEX 2 MG MT GUM
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 0536302906
|
| Hospital Charge Code |
0536302906
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.23
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.21
|
| Rate for Payer: Aetna Government |
$0.21
|
| Rate for Payer: Brighton Health Commercial |
$0.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.29
|
| Rate for Payer: EmblemHealth Commercial |
$0.21
|
| Rate for Payer: Group Health Inc Commercial |
$0.21
|
| Rate for Payer: Group Health Inc Medicare |
$0.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.21
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.28
|
|
|
NICOTINE POLACRILEX 2 MG MT GUM
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 0536302906
|
| Hospital Charge Code |
0536302906
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.21
|
|
|
NICOTINE POLACRILEX 2 MG MT GUM
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 0536136234
|
| Hospital Charge Code |
0536136234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.30
|
|
|
NICOTINE POLACRILEX 2 MG MT GUM
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 0536136234
|
| Hospital Charge Code |
0536136234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.33
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.30
|
| Rate for Payer: Aetna Government |
$0.30
|
| Rate for Payer: Brighton Health Commercial |
$0.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.48
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.41
|
| Rate for Payer: EmblemHealth Commercial |
$0.30
|
| Rate for Payer: Group Health Inc Commercial |
$0.30
|
| Rate for Payer: Group Health Inc Medicare |
$0.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.39
|
|
