|
DOBUTamine 1 mg/mL- 250 mL IVPB [CQCH]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
105919638
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of AZ Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
|
|
DOBUTamine 1 mg/mL- 250 mL IVPB [CQCH]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
105919638
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of AZ Commercial |
$0.06
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.01
|
| Rate for Payer: Banner UC Health Medicare |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.05
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.01
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.01
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of AZ Commercial |
$0.05
|
| Rate for Payer: Devoted Health Medicare |
$0.01
|
| Rate for Payer: Humana of AZ Medicare |
$0.01
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.05
|
| Rate for Payer: TriWest Medicare |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.04
|
| Rate for Payer: United Healthcare Medicare |
$0.01
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.01
|
|
|
docusate sodium 100 mg/10 mL Oral Liq [CQCH]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 121054410
|
| Hospital Charge Code |
105919774
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of AZ Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
|
|
docusate sodium 100 mg/10 mL Oral Liq [CQCH]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 121054410
|
| Hospital Charge Code |
105919774
|
|
Hospital Revenue Code
|
251
|
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of AZ Commercial |
$0.03
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.00
|
| Rate for Payer: Banner UC Health Medicare |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.00
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.00
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of AZ Commercial |
$0.02
|
| Rate for Payer: Devoted Health Medicare |
$0.01
|
| Rate for Payer: Humana of AZ Medicare |
$0.00
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.02
|
| Rate for Payer: TriWest Medicare |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.02
|
| Rate for Payer: United Healthcare Medicare |
$0.00
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.00
|
|
|
docusate sodium 100 mg Cap [CQCH]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 904645561
|
| Hospital Charge Code |
105919709
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of AZ Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
|
|
docusate sodium 100 mg Cap [CQCH]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 904645561
|
| Hospital Charge Code |
105919709
|
|
Hospital Revenue Code
|
251
|
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of AZ Commercial |
$0.03
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.00
|
| Rate for Payer: Banner UC Health Medicare |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.00
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.00
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of AZ Commercial |
$0.02
|
| Rate for Payer: Devoted Health Medicare |
$0.01
|
| Rate for Payer: Humana of AZ Medicare |
$0.00
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.02
|
| Rate for Payer: TriWest Medicare |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.02
|
| Rate for Payer: United Healthcare Medicare |
$0.00
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.00
|
|
|
donepezil 5 mg Tab [CQCH]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 60687029201
|
| Hospital Charge Code |
105919841
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of AZ Commercial |
$0.10
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.02
|
| Rate for Payer: Banner UC Health Medicare |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.07
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.02
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of AZ Commercial |
$0.07
|
| Rate for Payer: Devoted Health Medicare |
$0.02
|
| Rate for Payer: Humana of AZ Medicare |
$0.02
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.07
|
| Rate for Payer: TriWest Medicare |
$0.02
|
| Rate for Payer: United Healthcare Commercial |
$0.06
|
| Rate for Payer: United Healthcare Medicare |
$0.02
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.02
|
|
|
donepezil 5 mg Tab [CQCH]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 60687029201
|
| Hospital Charge Code |
105919841
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of AZ Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
|
|
DOPamine 1.6 mg/mL-250 mL IVPB [CQCH]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
105919908
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of AZ Commercial |
$0.03
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.00
|
| Rate for Payer: Banner UC Health Medicare |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.00
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.00
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of AZ Commercial |
$0.02
|
| Rate for Payer: Devoted Health Medicare |
$0.01
|
| Rate for Payer: Humana of AZ Medicare |
$0.00
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.02
|
| Rate for Payer: TriWest Medicare |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.02
|
| Rate for Payer: United Healthcare Medicare |
$0.00
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.00
|
|
|
DOPamine 1.6 mg/mL-250 mL IVPB [CQCH]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
105919908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of AZ Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
|
|
Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back
|
Facility
|
IP
|
$21,589.09
|
|
|
Service Code
|
APR-DRG 3042
|
| Hospital Charge Code |
APRDRG3043
|
| Min. Negotiated Rate |
$21,589.09 |
| Max. Negotiated Rate |
$21,589.09 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$21,589.09
|
| Rate for Payer: Mercy Care Medicaid |
$21,589.09
|
| Rate for Payer: NaphCare Correctional Healthcare |
$21,589.09
|
|
|
Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back
|
Facility
|
IP
|
$47,588.59
|
|
|
Service Code
|
APR-DRG 3044
|
| Hospital Charge Code |
APRDRG3041
|
| Min. Negotiated Rate |
$47,588.59 |
| Max. Negotiated Rate |
$47,588.59 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$47,588.59
|
| Rate for Payer: Mercy Care Medicaid |
$47,588.59
|
| Rate for Payer: NaphCare Correctional Healthcare |
$47,588.59
|
|
|
Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back
|
Facility
|
IP
|
$47,588.59
|
|
|
Service Code
|
APR-DRG 3044
|
| Hospital Charge Code |
APRDRG3043
|
| Min. Negotiated Rate |
$47,588.59 |
| Max. Negotiated Rate |
$47,588.59 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$47,588.59
|
| Rate for Payer: Mercy Care Medicaid |
$47,588.59
|
| Rate for Payer: NaphCare Correctional Healthcare |
$47,588.59
|
|
|
Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back
|
Facility
|
IP
|
$17,155.54
|
|
|
Service Code
|
APR-DRG 3041
|
| Hospital Charge Code |
APRDRG3042
|
| Min. Negotiated Rate |
$17,155.54 |
| Max. Negotiated Rate |
$17,155.54 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$17,155.54
|
| Rate for Payer: Mercy Care Medicaid |
$17,155.54
|
| Rate for Payer: NaphCare Correctional Healthcare |
$17,155.54
|
|
|
Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back
|
Facility
|
IP
|
$47,588.59
|
|
|
Service Code
|
APR-DRG 3044
|
| Hospital Charge Code |
APRDRG3044
|
| Min. Negotiated Rate |
$47,588.59 |
| Max. Negotiated Rate |
$47,588.59 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$47,588.59
|
| Rate for Payer: Mercy Care Medicaid |
$47,588.59
|
| Rate for Payer: NaphCare Correctional Healthcare |
$47,588.59
|
|
|
Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back
|
Facility
|
IP
|
$17,155.54
|
|
|
Service Code
|
APR-DRG 3041
|
| Hospital Charge Code |
APRDRG3041
|
| Min. Negotiated Rate |
$17,155.54 |
| Max. Negotiated Rate |
$17,155.54 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$17,155.54
|
| Rate for Payer: Mercy Care Medicaid |
$17,155.54
|
| Rate for Payer: NaphCare Correctional Healthcare |
$17,155.54
|
|
|
Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back
|
Facility
|
IP
|
$32,927.92
|
|
|
Service Code
|
APR-DRG 3043
|
| Hospital Charge Code |
APRDRG3044
|
| Min. Negotiated Rate |
$32,927.92 |
| Max. Negotiated Rate |
$32,927.92 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$32,927.92
|
| Rate for Payer: Mercy Care Medicaid |
$32,927.92
|
| Rate for Payer: NaphCare Correctional Healthcare |
$32,927.92
|
|
|
Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back
|
Facility
|
IP
|
$32,927.92
|
|
|
Service Code
|
APR-DRG 3043
|
| Hospital Charge Code |
APRDRG3042
|
| Min. Negotiated Rate |
$32,927.92 |
| Max. Negotiated Rate |
$32,927.92 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$32,927.92
|
| Rate for Payer: Mercy Care Medicaid |
$32,927.92
|
| Rate for Payer: NaphCare Correctional Healthcare |
$32,927.92
|
|
|
Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back
|
Facility
|
IP
|
$17,155.54
|
|
|
Service Code
|
APR-DRG 3041
|
| Hospital Charge Code |
APRDRG3044
|
| Min. Negotiated Rate |
$17,155.54 |
| Max. Negotiated Rate |
$17,155.54 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$17,155.54
|
| Rate for Payer: Mercy Care Medicaid |
$17,155.54
|
| Rate for Payer: NaphCare Correctional Healthcare |
$17,155.54
|
|
|
Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back
|
Facility
|
IP
|
$21,589.09
|
|
|
Service Code
|
APR-DRG 3042
|
| Hospital Charge Code |
APRDRG3041
|
| Min. Negotiated Rate |
$21,589.09 |
| Max. Negotiated Rate |
$21,589.09 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$21,589.09
|
| Rate for Payer: Mercy Care Medicaid |
$21,589.09
|
| Rate for Payer: NaphCare Correctional Healthcare |
$21,589.09
|
|
|
Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back
|
Facility
|
IP
|
$17,155.54
|
|
|
Service Code
|
APR-DRG 3041
|
| Hospital Charge Code |
APRDRG3043
|
| Min. Negotiated Rate |
$17,155.54 |
| Max. Negotiated Rate |
$17,155.54 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$17,155.54
|
| Rate for Payer: Mercy Care Medicaid |
$17,155.54
|
| Rate for Payer: NaphCare Correctional Healthcare |
$17,155.54
|
|
|
Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back
|
Facility
|
IP
|
$47,588.59
|
|
|
Service Code
|
APR-DRG 3044
|
| Hospital Charge Code |
APRDRG3042
|
| Min. Negotiated Rate |
$47,588.59 |
| Max. Negotiated Rate |
$47,588.59 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$47,588.59
|
| Rate for Payer: Mercy Care Medicaid |
$47,588.59
|
| Rate for Payer: NaphCare Correctional Healthcare |
$47,588.59
|
|
|
Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back
|
Facility
|
IP
|
$21,589.09
|
|
|
Service Code
|
APR-DRG 3042
|
| Hospital Charge Code |
APRDRG3044
|
| Min. Negotiated Rate |
$21,589.09 |
| Max. Negotiated Rate |
$21,589.09 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$21,589.09
|
| Rate for Payer: Mercy Care Medicaid |
$21,589.09
|
| Rate for Payer: NaphCare Correctional Healthcare |
$21,589.09
|
|
|
Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back
|
Facility
|
IP
|
$21,589.09
|
|
|
Service Code
|
APR-DRG 3042
|
| Hospital Charge Code |
APRDRG3042
|
| Min. Negotiated Rate |
$21,589.09 |
| Max. Negotiated Rate |
$21,589.09 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$21,589.09
|
| Rate for Payer: Mercy Care Medicaid |
$21,589.09
|
| Rate for Payer: NaphCare Correctional Healthcare |
$21,589.09
|
|
|
Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back
|
Facility
|
IP
|
$32,927.92
|
|
|
Service Code
|
APR-DRG 3043
|
| Hospital Charge Code |
APRDRG3043
|
| Min. Negotiated Rate |
$32,927.92 |
| Max. Negotiated Rate |
$32,927.92 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$32,927.92
|
| Rate for Payer: Mercy Care Medicaid |
$32,927.92
|
| Rate for Payer: NaphCare Correctional Healthcare |
$32,927.92
|
|
