|
melatonin 3 mg Tab UD [CQCH]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 50268052415
|
| Hospital Charge Code |
111571064
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of AZ Commercial |
$0.15
|
| Rate for Payer: Cash Price |
$0.13
|
|
|
memantine 10 mg Tab UD [CQCH]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 60687018457
|
| Hospital Charge Code |
107742580
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of AZ Commercial |
$0.27
|
| Rate for Payer: Cash Price |
$0.24
|
|
|
memantine 10 mg Tab UD [CQCH]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 60687018457
|
| Hospital Charge Code |
107742580
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of AZ Commercial |
$0.27
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.05
|
| Rate for Payer: Banner UC Health Medicare |
$0.05
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.20
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.05
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of AZ Commercial |
$0.20
|
| Rate for Payer: Devoted Health Medicare |
$0.05
|
| Rate for Payer: Humana of AZ Medicare |
$0.05
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.20
|
| Rate for Payer: TriWest Medicare |
$0.05
|
| Rate for Payer: United Healthcare Commercial |
$0.17
|
| Rate for Payer: United Healthcare Medicare |
$0.05
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.05
|
|
|
MEMOFIX DRILL BIT 1.7MM
|
Facility
|
OP
|
$1,505.00
|
|
| Hospital Charge Code |
24127788
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$238.39 |
| Max. Negotiated Rate |
$1,354.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,354.50
|
| Rate for Payer: Arizona Complete Health Allwell |
$240.80
|
| Rate for Payer: Banner UC Health Medicare |
$240.80
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$1,023.40
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$240.80
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$240.80
|
| Rate for Payer: Cash Price |
$1,204.00
|
| Rate for Payer: Cigna of AZ Commercial |
$1,053.50
|
| Rate for Payer: Devoted Health Medicare |
$270.90
|
| Rate for Payer: Humana of AZ Medicare |
$240.80
|
| Rate for Payer: Southwest Service Administrators UFCW |
$1,023.40
|
| Rate for Payer: TriWest Medicare |
$240.80
|
| Rate for Payer: United Healthcare Commercial |
$860.86
|
| Rate for Payer: United Healthcare Medicare |
$240.80
|
| Rate for Payer: Veterans Affairs TRICARE |
$238.39
|
|
|
MEMOFIX DRILL BIT 1.7MM
|
Facility
|
IP
|
$1,505.00
|
|
| Hospital Charge Code |
24127788
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,354.50 |
| Max. Negotiated Rate |
$1,354.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,354.50
|
| Rate for Payer: Cash Price |
$1,204.00
|
|
|
MEMOFIX NITINOL STAPLE 10MMX10MMX10MM
|
Facility
|
OP
|
$6,631.00
|
|
| Hospital Charge Code |
24358107
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,050.35 |
| Max. Negotiated Rate |
$5,967.90 |
| Rate for Payer: Aetna of AZ Commercial |
$5,967.90
|
| Rate for Payer: Arizona Complete Health Allwell |
$1,060.96
|
| Rate for Payer: Banner UC Health Medicare |
$1,060.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$4,509.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$1,060.96
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$1,060.96
|
| Rate for Payer: Cash Price |
$5,304.80
|
| Rate for Payer: Cigna of AZ Commercial |
$4,641.70
|
| Rate for Payer: Devoted Health Medicare |
$1,193.58
|
| Rate for Payer: Humana of AZ Medicare |
$1,060.96
|
| Rate for Payer: Southwest Service Administrators UFCW |
$4,509.08
|
| Rate for Payer: TriWest Medicare |
$1,060.96
|
| Rate for Payer: United Healthcare Commercial |
$3,792.93
|
| Rate for Payer: United Healthcare Medicare |
$1,060.96
|
| Rate for Payer: Veterans Affairs TRICARE |
$1,050.35
|
|
|
MEMOFIX NITINOL STAPLE 10MMX10MMX10MM
|
Facility
|
IP
|
$6,631.00
|
|
| Hospital Charge Code |
24358107
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5,967.90 |
| Max. Negotiated Rate |
$5,967.90 |
| Rate for Payer: Aetna of AZ Commercial |
$5,967.90
|
| Rate for Payer: Cash Price |
$5,304.80
|
|
|
MEMOFIX NITINOL STAPLE 12MMX12MMX12MM
|
Facility
|
OP
|
$6,631.00
|
|
| Hospital Charge Code |
24358109
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,050.35 |
| Max. Negotiated Rate |
$5,967.90 |
| Rate for Payer: Aetna of AZ Commercial |
$5,967.90
|
| Rate for Payer: Arizona Complete Health Allwell |
$1,060.96
|
| Rate for Payer: Banner UC Health Medicare |
$1,060.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$4,509.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$1,060.96
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$1,060.96
|
| Rate for Payer: Cash Price |
$5,304.80
|
| Rate for Payer: Cigna of AZ Commercial |
$4,641.70
|
| Rate for Payer: Devoted Health Medicare |
$1,193.58
|
| Rate for Payer: Humana of AZ Medicare |
$1,060.96
|
| Rate for Payer: Southwest Service Administrators UFCW |
$4,509.08
|
| Rate for Payer: TriWest Medicare |
$1,060.96
|
| Rate for Payer: United Healthcare Commercial |
$3,792.93
|
| Rate for Payer: United Healthcare Medicare |
$1,060.96
|
| Rate for Payer: Veterans Affairs TRICARE |
$1,050.35
|
|
|
MEMOFIX NITINOL STAPLE 12MMX12MMX12MM
|
Facility
|
IP
|
$6,631.00
|
|
| Hospital Charge Code |
24358109
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5,967.90 |
| Max. Negotiated Rate |
$5,967.90 |
| Rate for Payer: Aetna of AZ Commercial |
$5,967.90
|
| Rate for Payer: Cash Price |
$5,304.80
|
|
|
MEMOFIX NITINO STAPLE 8MMX8MMX8MM
|
Facility
|
OP
|
$3,448.00
|
|
| Hospital Charge Code |
24127792
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$546.16 |
| Max. Negotiated Rate |
$3,103.20 |
| Rate for Payer: Aetna of AZ Commercial |
$3,103.20
|
| Rate for Payer: Arizona Complete Health Allwell |
$551.68
|
| Rate for Payer: Banner UC Health Medicare |
$551.68
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$2,344.64
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$551.68
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$551.68
|
| Rate for Payer: Cash Price |
$2,758.40
|
| Rate for Payer: Cigna of AZ Commercial |
$2,413.60
|
| Rate for Payer: Devoted Health Medicare |
$620.64
|
| Rate for Payer: Humana of AZ Medicare |
$551.68
|
| Rate for Payer: Southwest Service Administrators UFCW |
$2,344.64
|
| Rate for Payer: TriWest Medicare |
$551.68
|
| Rate for Payer: United Healthcare Commercial |
$1,972.26
|
| Rate for Payer: United Healthcare Medicare |
$551.68
|
| Rate for Payer: Veterans Affairs TRICARE |
$546.16
|
|
|
MEMOFIX NITINO STAPLE 8MMX8MMX8MM
|
Facility
|
IP
|
$3,448.00
|
|
| Hospital Charge Code |
24127792
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3,103.20 |
| Max. Negotiated Rate |
$3,103.20 |
| Rate for Payer: Aetna of AZ Commercial |
$3,103.20
|
| Rate for Payer: Cash Price |
$2,758.40
|
|
|
MEMOFIX PIN 1.7MM
|
Facility
|
OP
|
$1,048.00
|
|
| Hospital Charge Code |
24127790
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$166.00 |
| Max. Negotiated Rate |
$943.20 |
| Rate for Payer: Aetna of AZ Commercial |
$943.20
|
| Rate for Payer: Arizona Complete Health Allwell |
$167.68
|
| Rate for Payer: Banner UC Health Medicare |
$167.68
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$712.64
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$167.68
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$167.68
|
| Rate for Payer: Cash Price |
$838.40
|
| Rate for Payer: Cigna of AZ Commercial |
$733.60
|
| Rate for Payer: Devoted Health Medicare |
$188.64
|
| Rate for Payer: Humana of AZ Medicare |
$167.68
|
| Rate for Payer: Southwest Service Administrators UFCW |
$712.64
|
| Rate for Payer: TriWest Medicare |
$167.68
|
| Rate for Payer: United Healthcare Commercial |
$599.46
|
| Rate for Payer: United Healthcare Medicare |
$167.68
|
| Rate for Payer: Veterans Affairs TRICARE |
$166.00
|
|
|
MEMOFIX PIN 1.7MM
|
Facility
|
IP
|
$1,048.00
|
|
| Hospital Charge Code |
24127790
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$943.20 |
| Max. Negotiated Rate |
$943.20 |
| Rate for Payer: Aetna of AZ Commercial |
$943.20
|
| Rate for Payer: Cash Price |
$838.40
|
|
|
Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for
|
Facility
|
OP
|
$393.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
749835
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.25 |
| Max. Negotiated Rate |
$353.70 |
| Rate for Payer: Aetna of AZ Commercial |
$353.70
|
| Rate for Payer: Arizona Complete Health Allwell |
$62.88
|
| Rate for Payer: Banner UC Health Medicare |
$62.88
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$267.24
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$62.88
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$62.88
|
| Rate for Payer: Cash Price |
$314.40
|
| Rate for Payer: Cigna of AZ Commercial |
$275.10
|
| Rate for Payer: Devoted Health Medicare |
$70.74
|
| Rate for Payer: Humana of AZ Medicare |
$62.88
|
| Rate for Payer: Southwest Service Administrators UFCW |
$267.24
|
| Rate for Payer: TriWest Medicare |
$62.88
|
| Rate for Payer: United Healthcare Commercial |
$224.80
|
| Rate for Payer: United Healthcare Medicare |
$62.88
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$74.67
|
| Rate for Payer: Veterans Affairs TRICARE |
$62.25
|
|
|
Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for
|
Facility
|
IP
|
$393.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
749835
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$353.70 |
| Max. Negotiated Rate |
$353.70 |
| Rate for Payer: Aetna of AZ Commercial |
$353.70
|
| Rate for Payer: Cash Price |
$314.40
|
|
|
MENINGOCOCCAL POLYSACCHARIDE VACCINE CQCH
|
Facility
|
OP
|
$292.00
|
|
|
Service Code
|
CPT 90733
|
| Hospital Charge Code |
24076228
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.25 |
| Max. Negotiated Rate |
$262.80 |
| Rate for Payer: Aetna of AZ Commercial |
$262.80
|
| Rate for Payer: Arizona Complete Health Allwell |
$46.72
|
| Rate for Payer: Banner UC Health Medicare |
$46.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$198.56
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$46.72
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$46.72
|
| Rate for Payer: Cash Price |
$233.60
|
| Rate for Payer: Cigna of AZ Commercial |
$204.40
|
| Rate for Payer: Devoted Health Medicare |
$52.56
|
| Rate for Payer: Humana of AZ Medicare |
$46.72
|
| Rate for Payer: Southwest Service Administrators UFCW |
$198.56
|
| Rate for Payer: TriWest Medicare |
$46.72
|
| Rate for Payer: United Healthcare Commercial |
$167.02
|
| Rate for Payer: United Healthcare Medicare |
$46.72
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$55.48
|
| Rate for Payer: Veterans Affairs TRICARE |
$46.25
|
|
|
MENINGOCOCCAL POLYSACCHARIDE VACCINE CQCH
|
Facility
|
IP
|
$292.00
|
|
|
Service Code
|
CPT 90733
|
| Hospital Charge Code |
24076228
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$262.80 |
| Max. Negotiated Rate |
$262.80 |
| Rate for Payer: Aetna of AZ Commercial |
$262.80
|
| Rate for Payer: Cash Price |
$233.60
|
|
|
Menstrual And Other Female Reproductive System Disorders
|
Facility
|
IP
|
$11,878.91
|
|
|
Service Code
|
APR-DRG 5324
|
| Hospital Charge Code |
APRDRG5323
|
| Min. Negotiated Rate |
$11,878.91 |
| Max. Negotiated Rate |
$11,878.91 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$11,878.91
|
| Rate for Payer: Mercy Care Medicaid |
$11,878.91
|
| Rate for Payer: NaphCare Correctional Healthcare |
$11,878.91
|
|
|
Menstrual And Other Female Reproductive System Disorders
|
Facility
|
IP
|
$5,450.58
|
|
|
Service Code
|
APR-DRG 5323
|
| Hospital Charge Code |
APRDRG5324
|
| Min. Negotiated Rate |
$5,450.58 |
| Max. Negotiated Rate |
$5,450.58 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,450.58
|
| Rate for Payer: Mercy Care Medicaid |
$5,450.58
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,450.58
|
|
|
Menstrual And Other Female Reproductive System Disorders
|
Facility
|
IP
|
$3,737.06
|
|
|
Service Code
|
APR-DRG 5322
|
| Hospital Charge Code |
APRDRG5322
|
| Min. Negotiated Rate |
$3,737.06 |
| Max. Negotiated Rate |
$3,737.06 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,737.06
|
| Rate for Payer: Mercy Care Medicaid |
$3,737.06
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,737.06
|
|
|
Menstrual And Other Female Reproductive System Disorders
|
Facility
|
IP
|
$3,118.42
|
|
|
Service Code
|
APR-DRG 5321
|
| Hospital Charge Code |
APRDRG5322
|
| Min. Negotiated Rate |
$3,118.42 |
| Max. Negotiated Rate |
$3,118.42 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,118.42
|
| Rate for Payer: Mercy Care Medicaid |
$3,118.42
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,118.42
|
|
|
Menstrual And Other Female Reproductive System Disorders
|
Facility
|
IP
|
$11,878.91
|
|
|
Service Code
|
APR-DRG 5324
|
| Hospital Charge Code |
APRDRG5324
|
| Min. Negotiated Rate |
$11,878.91 |
| Max. Negotiated Rate |
$11,878.91 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$11,878.91
|
| Rate for Payer: Mercy Care Medicaid |
$11,878.91
|
| Rate for Payer: NaphCare Correctional Healthcare |
$11,878.91
|
|
|
Menstrual And Other Female Reproductive System Disorders
|
Facility
|
IP
|
$5,450.58
|
|
|
Service Code
|
APR-DRG 5323
|
| Hospital Charge Code |
APRDRG5322
|
| Min. Negotiated Rate |
$5,450.58 |
| Max. Negotiated Rate |
$5,450.58 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,450.58
|
| Rate for Payer: Mercy Care Medicaid |
$5,450.58
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,450.58
|
|
|
Menstrual And Other Female Reproductive System Disorders
|
Facility
|
IP
|
$3,118.42
|
|
|
Service Code
|
APR-DRG 5321
|
| Hospital Charge Code |
APRDRG5323
|
| Min. Negotiated Rate |
$3,118.42 |
| Max. Negotiated Rate |
$3,118.42 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,118.42
|
| Rate for Payer: Mercy Care Medicaid |
$3,118.42
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,118.42
|
|
|
Menstrual And Other Female Reproductive System Disorders
|
Facility
|
IP
|
$3,737.06
|
|
|
Service Code
|
APR-DRG 5322
|
| Hospital Charge Code |
APRDRG5321
|
| Min. Negotiated Rate |
$3,737.06 |
| Max. Negotiated Rate |
$3,737.06 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,737.06
|
| Rate for Payer: Mercy Care Medicaid |
$3,737.06
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,737.06
|
|
