|
charcoal-sorbitol 25 g Oral Susp 120 mL [CQCH]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 66689020304
|
| Hospital Charge Code |
105916052
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of AZ Commercial |
$0.16
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.03
|
| Rate for Payer: Banner UC Health Medicare |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.12
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.03
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.03
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of AZ Commercial |
$0.12
|
| Rate for Payer: Devoted Health Medicare |
$0.03
|
| Rate for Payer: Humana of AZ Medicare |
$0.03
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.12
|
| Rate for Payer: TriWest Medicare |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.10
|
| Rate for Payer: United Healthcare Medicare |
$0.03
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.03
|
|
|
CHECKMATE EXTENSION SET ANESTHESIA
|
Facility
|
IP
|
$63.00
|
|
| Hospital Charge Code |
22355567
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$56.70 |
| Max. Negotiated Rate |
$56.70 |
| Rate for Payer: Aetna of AZ Commercial |
$56.70
|
| Rate for Payer: Cash Price |
$50.40
|
|
|
CHECKMATE EXTENSION SET ANESTHESIA
|
Facility
|
OP
|
$63.00
|
|
| Hospital Charge Code |
22355567
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.98 |
| Max. Negotiated Rate |
$56.70 |
| Rate for Payer: Aetna of AZ Commercial |
$56.70
|
| Rate for Payer: Arizona Complete Health Allwell |
$10.08
|
| Rate for Payer: Banner UC Health Medicare |
$10.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$42.84
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$10.08
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$10.08
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna of AZ Commercial |
$44.10
|
| Rate for Payer: Devoted Health Medicare |
$11.34
|
| Rate for Payer: Humana of AZ Medicare |
$10.08
|
| Rate for Payer: Southwest Service Administrators UFCW |
$42.84
|
| Rate for Payer: TriWest Medicare |
$10.08
|
| Rate for Payer: United Healthcare Commercial |
$36.04
|
| Rate for Payer: United Healthcare Medicare |
$10.08
|
| Rate for Payer: Veterans Affairs TRICARE |
$9.98
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$44,263.25
|
|
|
Service Code
|
APR-DRG 6954
|
| Hospital Charge Code |
APRDRG6951
|
| Min. Negotiated Rate |
$44,263.25 |
| Max. Negotiated Rate |
$44,263.25 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$44,263.25
|
| Rate for Payer: Mercy Care Medicaid |
$44,263.25
|
| Rate for Payer: NaphCare Correctional Healthcare |
$44,263.25
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$16,241.62
|
|
|
Service Code
|
APR-DRG 6953
|
| Hospital Charge Code |
APRDRG6952
|
| Min. Negotiated Rate |
$16,241.62 |
| Max. Negotiated Rate |
$16,241.62 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$16,241.62
|
| Rate for Payer: Mercy Care Medicaid |
$16,241.62
|
| Rate for Payer: NaphCare Correctional Healthcare |
$16,241.62
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$6,175.13
|
|
|
Service Code
|
APR-DRG 6952
|
| Hospital Charge Code |
APRDRG6952
|
| Min. Negotiated Rate |
$6,175.13 |
| Max. Negotiated Rate |
$6,175.13 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,175.13
|
| Rate for Payer: Mercy Care Medicaid |
$6,175.13
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,175.13
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$6,175.13
|
|
|
Service Code
|
APR-DRG 6952
|
| Hospital Charge Code |
APRDRG6951
|
| Min. Negotiated Rate |
$6,175.13 |
| Max. Negotiated Rate |
$6,175.13 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,175.13
|
| Rate for Payer: Mercy Care Medicaid |
$6,175.13
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,175.13
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$6,175.13
|
|
|
Service Code
|
APR-DRG 6952
|
| Hospital Charge Code |
APRDRG6954
|
| Min. Negotiated Rate |
$6,175.13 |
| Max. Negotiated Rate |
$6,175.13 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,175.13
|
| Rate for Payer: Mercy Care Medicaid |
$6,175.13
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,175.13
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$16,241.62
|
|
|
Service Code
|
APR-DRG 6953
|
| Hospital Charge Code |
APRDRG6954
|
| Min. Negotiated Rate |
$16,241.62 |
| Max. Negotiated Rate |
$16,241.62 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$16,241.62
|
| Rate for Payer: Mercy Care Medicaid |
$16,241.62
|
| Rate for Payer: NaphCare Correctional Healthcare |
$16,241.62
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$44,263.25
|
|
|
Service Code
|
APR-DRG 6954
|
| Hospital Charge Code |
APRDRG6952
|
| Min. Negotiated Rate |
$44,263.25 |
| Max. Negotiated Rate |
$44,263.25 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$44,263.25
|
| Rate for Payer: Mercy Care Medicaid |
$44,263.25
|
| Rate for Payer: NaphCare Correctional Healthcare |
$44,263.25
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$16,241.62
|
|
|
Service Code
|
APR-DRG 6953
|
| Hospital Charge Code |
APRDRG6951
|
| Min. Negotiated Rate |
$16,241.62 |
| Max. Negotiated Rate |
$16,241.62 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$16,241.62
|
| Rate for Payer: Mercy Care Medicaid |
$16,241.62
|
| Rate for Payer: NaphCare Correctional Healthcare |
$16,241.62
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$44,263.25
|
|
|
Service Code
|
APR-DRG 6954
|
| Hospital Charge Code |
APRDRG6953
|
| Min. Negotiated Rate |
$44,263.25 |
| Max. Negotiated Rate |
$44,263.25 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$44,263.25
|
| Rate for Payer: Mercy Care Medicaid |
$44,263.25
|
| Rate for Payer: NaphCare Correctional Healthcare |
$44,263.25
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$16,241.62
|
|
|
Service Code
|
APR-DRG 6953
|
| Hospital Charge Code |
APRDRG6953
|
| Min. Negotiated Rate |
$16,241.62 |
| Max. Negotiated Rate |
$16,241.62 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$16,241.62
|
| Rate for Payer: Mercy Care Medicaid |
$16,241.62
|
| Rate for Payer: NaphCare Correctional Healthcare |
$16,241.62
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$6,175.13
|
|
|
Service Code
|
APR-DRG 6951
|
| Hospital Charge Code |
APRDRG6954
|
| Min. Negotiated Rate |
$6,175.13 |
| Max. Negotiated Rate |
$6,175.13 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,175.13
|
| Rate for Payer: Mercy Care Medicaid |
$6,175.13
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,175.13
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$6,175.13
|
|
|
Service Code
|
APR-DRG 6951
|
| Hospital Charge Code |
APRDRG6952
|
| Min. Negotiated Rate |
$6,175.13 |
| Max. Negotiated Rate |
$6,175.13 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,175.13
|
| Rate for Payer: Mercy Care Medicaid |
$6,175.13
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,175.13
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$44,263.25
|
|
|
Service Code
|
APR-DRG 6954
|
| Hospital Charge Code |
APRDRG6954
|
| Min. Negotiated Rate |
$44,263.25 |
| Max. Negotiated Rate |
$44,263.25 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$44,263.25
|
| Rate for Payer: Mercy Care Medicaid |
$44,263.25
|
| Rate for Payer: NaphCare Correctional Healthcare |
$44,263.25
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$6,175.13
|
|
|
Service Code
|
APR-DRG 6951
|
| Hospital Charge Code |
APRDRG6953
|
| Min. Negotiated Rate |
$6,175.13 |
| Max. Negotiated Rate |
$6,175.13 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,175.13
|
| Rate for Payer: Mercy Care Medicaid |
$6,175.13
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,175.13
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$6,175.13
|
|
|
Service Code
|
APR-DRG 6952
|
| Hospital Charge Code |
APRDRG6953
|
| Min. Negotiated Rate |
$6,175.13 |
| Max. Negotiated Rate |
$6,175.13 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,175.13
|
| Rate for Payer: Mercy Care Medicaid |
$6,175.13
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,175.13
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$6,175.13
|
|
|
Service Code
|
APR-DRG 6951
|
| Hospital Charge Code |
APRDRG6951
|
| Min. Negotiated Rate |
$6,175.13 |
| Max. Negotiated Rate |
$6,175.13 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,175.13
|
| Rate for Payer: Mercy Care Medicaid |
$6,175.13
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,175.13
|
|
|
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC
|
Facility
|
IP
|
$62,091.42
|
|
|
Service Code
|
MSDRG 837
|
| Min. Negotiated Rate |
$62,091.42 |
| Max. Negotiated Rate |
$62,091.42 |
| Rate for Payer: Seven Corners Travel Insurance |
$62,091.42
|
|
|
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT
|
Facility
|
IP
|
$26,977.84
|
|
|
Service Code
|
MSDRG 838
|
| Min. Negotiated Rate |
$26,977.84 |
| Max. Negotiated Rate |
$26,977.84 |
| Rate for Payer: Seven Corners Travel Insurance |
$26,977.84
|
|
|
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC
|
Facility
|
IP
|
$18,661.15
|
|
|
Service Code
|
MSDRG 839
|
| Min. Negotiated Rate |
$18,661.15 |
| Max. Negotiated Rate |
$18,661.15 |
| Rate for Payer: Seven Corners Travel Insurance |
$18,661.15
|
|
|
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC
|
Facility
|
IP
|
$16,931.88
|
|
|
Service Code
|
MSDRG 847
|
| Min. Negotiated Rate |
$16,931.88 |
| Max. Negotiated Rate |
$16,931.88 |
| Rate for Payer: Seven Corners Travel Insurance |
$16,931.88
|
|
|
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC
|
Facility
|
IP
|
$33,505.85
|
|
|
Service Code
|
MSDRG 846
|
| Min. Negotiated Rate |
$33,505.85 |
| Max. Negotiated Rate |
$33,505.85 |
| Rate for Payer: Seven Corners Travel Insurance |
$33,505.85
|
|
|
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC
|
Facility
|
IP
|
$11,118.35
|
|
|
Service Code
|
MSDRG 848
|
| Min. Negotiated Rate |
$11,118.35 |
| Max. Negotiated Rate |
$11,118.35 |
| Rate for Payer: Seven Corners Travel Insurance |
$11,118.35
|
|
