|
Breast Procedures Except Mastectomy
|
Facility
|
IP
|
$24,191.29
|
|
|
Service Code
|
APR-DRG 3634
|
| Hospital Charge Code |
APRDRG3633
|
| Min. Negotiated Rate |
$24,191.29 |
| Max. Negotiated Rate |
$24,191.29 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$24,191.29
|
| Rate for Payer: Mercy Care Medicaid |
$24,191.29
|
| Rate for Payer: NaphCare Correctional Healthcare |
$24,191.29
|
|
|
Breast Procedures Except Mastectomy
|
Facility
|
IP
|
$13,972.59
|
|
|
Service Code
|
APR-DRG 3632
|
| Hospital Charge Code |
APRDRG3634
|
| Min. Negotiated Rate |
$13,972.59 |
| Max. Negotiated Rate |
$13,972.59 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$13,972.59
|
| Rate for Payer: Mercy Care Medicaid |
$13,972.59
|
| Rate for Payer: NaphCare Correctional Healthcare |
$13,972.59
|
|
|
BREATHING CIRCUIT
|
Facility
|
IP
|
$27.00
|
|
| Hospital Charge Code |
22355324
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$24.30 |
| Max. Negotiated Rate |
$24.30 |
| Rate for Payer: Aetna of AZ Commercial |
$24.30
|
| Rate for Payer: Cash Price |
$21.60
|
|
|
BREATHING CIRCUIT
|
Facility
|
OP
|
$27.00
|
|
| Hospital Charge Code |
22355324
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.28 |
| Max. Negotiated Rate |
$24.30 |
| Rate for Payer: Aetna of AZ Commercial |
$24.30
|
| Rate for Payer: Arizona Complete Health Allwell |
$4.32
|
| Rate for Payer: Banner UC Health Medicare |
$4.32
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$18.36
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$4.32
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$4.32
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna of AZ Commercial |
$18.90
|
| Rate for Payer: Devoted Health Medicare |
$4.86
|
| Rate for Payer: Humana of AZ Medicare |
$4.32
|
| Rate for Payer: Southwest Service Administrators UFCW |
$18.36
|
| Rate for Payer: TriWest Medicare |
$4.32
|
| Rate for Payer: United Healthcare Commercial |
$15.44
|
| Rate for Payer: United Healthcare Medicare |
$4.32
|
| Rate for Payer: Veterans Affairs TRICARE |
$4.28
|
|
|
BREATHING CIRCUIT PED
|
Facility
|
OP
|
$96.00
|
|
| Hospital Charge Code |
22355318
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.21 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Aetna of AZ Commercial |
$86.40
|
| Rate for Payer: Arizona Complete Health Allwell |
$15.36
|
| Rate for Payer: Banner UC Health Medicare |
$15.36
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$65.28
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$15.36
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$15.36
|
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Cigna of AZ Commercial |
$67.20
|
| Rate for Payer: Devoted Health Medicare |
$17.28
|
| Rate for Payer: Humana of AZ Medicare |
$15.36
|
| Rate for Payer: Southwest Service Administrators UFCW |
$65.28
|
| Rate for Payer: TriWest Medicare |
$15.36
|
| Rate for Payer: United Healthcare Commercial |
$54.91
|
| Rate for Payer: United Healthcare Medicare |
$15.36
|
| Rate for Payer: Veterans Affairs TRICARE |
$15.21
|
|
|
BREATHING CIRCUIT PED
|
Facility
|
IP
|
$96.00
|
|
| Hospital Charge Code |
22355318
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$86.40 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Aetna of AZ Commercial |
$86.40
|
| Rate for Payer: Cash Price |
$76.80
|
|
|
brompheniramine-pseudoephedrine 118 mL Bulk Liq [CQCH]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 603085194
|
| Hospital Charge Code |
107994381
|
|
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
|
|
|
brompheniramine-pseudoephedrine 118 mL Bulk Liq [CQCH]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 603085194
|
| Hospital Charge Code |
107994381
|
|
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
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$3,197.68
|
|
|
Service Code
|
APR-DRG 1382
|
| Hospital Charge Code |
APRDRG1382
|
| Min. Negotiated Rate |
$3,197.68 |
| Max. Negotiated Rate |
$3,197.68 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,197.68
|
| Rate for Payer: Mercy Care Medicaid |
$3,197.68
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,197.68
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$3,197.68
|
|
|
Service Code
|
APR-DRG 1382
|
| Hospital Charge Code |
APRDRG1384
|
| Min. Negotiated Rate |
$3,197.68 |
| Max. Negotiated Rate |
$3,197.68 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,197.68
|
| Rate for Payer: Mercy Care Medicaid |
$3,197.68
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,197.68
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$3,197.68
|
|
|
Service Code
|
APR-DRG 1382
|
| Hospital Charge Code |
APRDRG1381
|
| Min. Negotiated Rate |
$3,197.68 |
| Max. Negotiated Rate |
$3,197.68 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,197.68
|
| Rate for Payer: Mercy Care Medicaid |
$3,197.68
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,197.68
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$5,424.63
|
|
|
Service Code
|
APR-DRG 1383
|
| Hospital Charge Code |
APRDRG1384
|
| Min. Negotiated Rate |
$5,424.63 |
| Max. Negotiated Rate |
$5,424.63 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,424.63
|
| Rate for Payer: Mercy Care Medicaid |
$5,424.63
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,424.63
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$12,683.42
|
|
|
Service Code
|
APR-DRG 1384
|
| Hospital Charge Code |
APRDRG1384
|
| Min. Negotiated Rate |
$12,683.42 |
| Max. Negotiated Rate |
$12,683.42 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$12,683.42
|
| Rate for Payer: Mercy Care Medicaid |
$12,683.42
|
| Rate for Payer: NaphCare Correctional Healthcare |
$12,683.42
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$12,683.42
|
|
|
Service Code
|
APR-DRG 1384
|
| Hospital Charge Code |
APRDRG1383
|
| Min. Negotiated Rate |
$12,683.42 |
| Max. Negotiated Rate |
$12,683.42 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$12,683.42
|
| Rate for Payer: Mercy Care Medicaid |
$12,683.42
|
| Rate for Payer: NaphCare Correctional Healthcare |
$12,683.42
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$12,683.42
|
|
|
Service Code
|
APR-DRG 1384
|
| Hospital Charge Code |
APRDRG1381
|
| Min. Negotiated Rate |
$12,683.42 |
| Max. Negotiated Rate |
$12,683.42 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$12,683.42
|
| Rate for Payer: Mercy Care Medicaid |
$12,683.42
|
| Rate for Payer: NaphCare Correctional Healthcare |
$12,683.42
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$5,424.63
|
|
|
Service Code
|
APR-DRG 1383
|
| Hospital Charge Code |
APRDRG1381
|
| Min. Negotiated Rate |
$5,424.63 |
| Max. Negotiated Rate |
$5,424.63 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,424.63
|
| Rate for Payer: Mercy Care Medicaid |
$5,424.63
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,424.63
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$2,151.19
|
|
|
Service Code
|
APR-DRG 1381
|
| Hospital Charge Code |
APRDRG1381
|
| Min. Negotiated Rate |
$2,151.19 |
| Max. Negotiated Rate |
$2,151.19 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$2,151.19
|
| Rate for Payer: Mercy Care Medicaid |
$2,151.19
|
| Rate for Payer: NaphCare Correctional Healthcare |
$2,151.19
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$2,151.19
|
|
|
Service Code
|
APR-DRG 1381
|
| Hospital Charge Code |
APRDRG1383
|
| Min. Negotiated Rate |
$2,151.19 |
| Max. Negotiated Rate |
$2,151.19 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$2,151.19
|
| Rate for Payer: Mercy Care Medicaid |
$2,151.19
|
| Rate for Payer: NaphCare Correctional Healthcare |
$2,151.19
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$2,151.19
|
|
|
Service Code
|
APR-DRG 1381
|
| Hospital Charge Code |
APRDRG1382
|
| Min. Negotiated Rate |
$2,151.19 |
| Max. Negotiated Rate |
$2,151.19 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$2,151.19
|
| Rate for Payer: Mercy Care Medicaid |
$2,151.19
|
| Rate for Payer: NaphCare Correctional Healthcare |
$2,151.19
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$2,151.19
|
|
|
Service Code
|
APR-DRG 1381
|
| Hospital Charge Code |
APRDRG1384
|
| Min. Negotiated Rate |
$2,151.19 |
| Max. Negotiated Rate |
$2,151.19 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$2,151.19
|
| Rate for Payer: Mercy Care Medicaid |
$2,151.19
|
| Rate for Payer: NaphCare Correctional Healthcare |
$2,151.19
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$3,197.68
|
|
|
Service Code
|
APR-DRG 1382
|
| Hospital Charge Code |
APRDRG1383
|
| Min. Negotiated Rate |
$3,197.68 |
| Max. Negotiated Rate |
$3,197.68 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,197.68
|
| Rate for Payer: Mercy Care Medicaid |
$3,197.68
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,197.68
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$12,683.42
|
|
|
Service Code
|
APR-DRG 1384
|
| Hospital Charge Code |
APRDRG1382
|
| Min. Negotiated Rate |
$12,683.42 |
| Max. Negotiated Rate |
$12,683.42 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$12,683.42
|
| Rate for Payer: Mercy Care Medicaid |
$12,683.42
|
| Rate for Payer: NaphCare Correctional Healthcare |
$12,683.42
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$5,424.63
|
|
|
Service Code
|
APR-DRG 1383
|
| Hospital Charge Code |
APRDRG1383
|
| Min. Negotiated Rate |
$5,424.63 |
| Max. Negotiated Rate |
$5,424.63 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,424.63
|
| Rate for Payer: Mercy Care Medicaid |
$5,424.63
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,424.63
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$5,424.63
|
|
|
Service Code
|
APR-DRG 1383
|
| Hospital Charge Code |
APRDRG1382
|
| Min. Negotiated Rate |
$5,424.63 |
| Max. Negotiated Rate |
$5,424.63 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,424.63
|
| Rate for Payer: Mercy Care Medicaid |
$5,424.63
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,424.63
|
|
|
BRONCHITIS AND ASTHMA WITH CC/MCC
|
Facility
|
IP
|
$12,661.69
|
|
|
Service Code
|
MSDRG 202
|
| Min. Negotiated Rate |
$12,661.69 |
| Max. Negotiated Rate |
$12,661.69 |
| Rate for Payer: Seven Corners Travel Insurance |
$12,661.69
|
|
