|
buprenorphine 8 mg Tab [CQCH]
|
Facility
|
IP
|
$0.54
|
|
|
Service Code
|
HCPCS J0571
|
| Hospital Charge Code |
224460214
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Aetna of AZ Commercial |
$0.49
|
| Rate for Payer: Cash Price |
$0.43
|
|
|
buprenorphine 8 mg Tab [CQCH]
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
HCPCS J0571
|
| Hospital Charge Code |
224460214
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Aetna of AZ Commercial |
$0.49
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.09
|
| Rate for Payer: Banner UC Health Medicare |
$0.09
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.37
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.09
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.09
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of AZ Commercial |
$0.35
|
| Rate for Payer: Devoted Health Medicare |
$0.10
|
| Rate for Payer: Humana of AZ Medicare |
$0.09
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.37
|
| Rate for Payer: TriWest Medicare |
$0.09
|
| Rate for Payer: United Healthcare Commercial |
$0.31
|
| Rate for Payer: United Healthcare Medicare |
$0.09
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.09
|
|
|
buPROPion 150 mg DR Tab [CQCH]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 904658561
|
| Hospital Charge Code |
105913649
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of AZ Commercial |
$0.44
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.08
|
| Rate for Payer: Banner UC Health Medicare |
$0.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.33
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.08
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of AZ Commercial |
$0.32
|
| Rate for Payer: Devoted Health Medicare |
$0.09
|
| Rate for Payer: Humana of AZ Medicare |
$0.08
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.33
|
| Rate for Payer: TriWest Medicare |
$0.08
|
| Rate for Payer: United Healthcare Commercial |
$0.28
|
| Rate for Payer: United Healthcare Medicare |
$0.08
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.08
|
|
|
buPROPion 150 mg DR Tab [CQCH]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 904658561
|
| Hospital Charge Code |
105913649
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of AZ Commercial |
$0.44
|
| Rate for Payer: Cash Price |
$0.39
|
|
|
Burch (secondary repair)
|
Facility
|
IP
|
$4,342.00
|
|
|
Service Code
|
CPT 51841
|
| Hospital Charge Code |
27267813
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,907.80 |
| Max. Negotiated Rate |
$3,907.80 |
| Rate for Payer: Aetna of AZ Commercial |
$3,907.80
|
| Rate for Payer: Cash Price |
$3,473.60
|
|
|
Burch (secondary repair)
|
Facility
|
OP
|
$4,342.00
|
|
|
Service Code
|
CPT 51841
|
| Hospital Charge Code |
27267813
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$687.77 |
| Max. Negotiated Rate |
$4,169.00 |
| Rate for Payer: Aetna of AZ Commercial |
$3,907.80
|
| Rate for Payer: Arizona Complete Health Allwell |
$694.72
|
| Rate for Payer: Banner UC Health Medicare |
$694.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$2,952.56
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$694.72
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$694.72
|
| Rate for Payer: Cash Price |
$3,473.60
|
| Rate for Payer: Cash Price |
$3,473.60
|
| Rate for Payer: Cigna of AZ Commercial |
$2,171.00
|
| Rate for Payer: Devoted Health Medicare |
$781.56
|
| Rate for Payer: Humana of AZ Medicare |
$694.72
|
| Rate for Payer: Southwest Service Administrators UFCW |
$2,952.56
|
| Rate for Payer: TriWest Medicare |
$694.72
|
| Rate for Payer: United Healthcare Commercial |
$4,169.00
|
| Rate for Payer: United Healthcare Medicare |
$694.72
|
| Rate for Payer: Veterans Affairs TRICARE |
$687.77
|
|
|
Burch urethropexy without TAH simple
|
Facility
|
IP
|
$3,570.00
|
|
|
Service Code
|
CPT 51840
|
| Hospital Charge Code |
27291787
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,213.00 |
| Max. Negotiated Rate |
$3,213.00 |
| Rate for Payer: Aetna of AZ Commercial |
$3,213.00
|
| Rate for Payer: Cash Price |
$2,856.00
|
|
|
Burch urethropexy without TAH simple
|
Facility
|
OP
|
$3,570.00
|
|
|
Service Code
|
CPT 51840
|
| Hospital Charge Code |
27291787
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$565.49 |
| Max. Negotiated Rate |
$7,740.14 |
| Rate for Payer: Aetna of AZ Commercial |
$3,213.00
|
| Rate for Payer: Arizona Complete Health Allwell |
$571.20
|
| Rate for Payer: Banner UC Health Medicare |
$1,698.98
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$2,427.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$571.20
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$571.20
|
| Rate for Payer: Cash Price |
$2,856.00
|
| Rate for Payer: Cash Price |
$2,856.00
|
| Rate for Payer: Cash Price |
$2,856.00
|
| Rate for Payer: Cigna of AZ Commercial |
$1,785.00
|
| Rate for Payer: Devoted Health Medicare |
$642.60
|
| Rate for Payer: Humana of AZ Medicare |
$571.20
|
| Rate for Payer: NaphCare Correctional Healthcare |
$1,698.98
|
| Rate for Payer: Seven Corners Travel Insurance |
$7,740.14
|
| Rate for Payer: Southwest Service Administrators UFCW |
$2,427.60
|
| Rate for Payer: TriWest Medicare |
$571.20
|
| Rate for Payer: United Healthcare Commercial |
$4,169.00
|
| Rate for Payer: United Healthcare Medicare |
$571.20
|
| Rate for Payer: Veterans Affairs TRICARE |
$565.49
|
|
|
BURETTE SET BURETROL
|
Facility
|
OP
|
$95.00
|
|
| Hospital Charge Code |
22355314
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.05 |
| Max. Negotiated Rate |
$85.50 |
| Rate for Payer: Aetna of AZ Commercial |
$85.50
|
| Rate for Payer: Arizona Complete Health Allwell |
$15.20
|
| Rate for Payer: Banner UC Health Medicare |
$15.20
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$64.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$15.20
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$15.20
|
| Rate for Payer: Cash Price |
$76.00
|
| Rate for Payer: Cigna of AZ Commercial |
$66.50
|
| Rate for Payer: Devoted Health Medicare |
$17.10
|
| Rate for Payer: Humana of AZ Medicare |
$15.20
|
| Rate for Payer: Southwest Service Administrators UFCW |
$64.60
|
| Rate for Payer: TriWest Medicare |
$15.20
|
| Rate for Payer: United Healthcare Commercial |
$54.34
|
| Rate for Payer: United Healthcare Medicare |
$15.20
|
| Rate for Payer: Veterans Affairs TRICARE |
$15.05
|
|
|
BURETTE SET BURETROL
|
Facility
|
IP
|
$95.00
|
|
| Hospital Charge Code |
22355314
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$85.50 |
| Max. Negotiated Rate |
$85.50 |
| Rate for Payer: Aetna of AZ Commercial |
$85.50
|
| Rate for Payer: Cash Price |
$76.00
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$29,190.87
|
|
|
Service Code
|
APR-DRG 8423
|
| Hospital Charge Code |
APRDRG8421
|
| Min. Negotiated Rate |
$29,190.87 |
| Max. Negotiated Rate |
$29,190.87 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$29,190.87
|
| Rate for Payer: Mercy Care Medicaid |
$29,190.87
|
| Rate for Payer: NaphCare Correctional Healthcare |
$29,190.87
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$15,824.99
|
|
|
Service Code
|
APR-DRG 8422
|
| Hospital Charge Code |
APRDRG8423
|
| Min. Negotiated Rate |
$15,824.99 |
| Max. Negotiated Rate |
$15,824.99 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$15,824.99
|
| Rate for Payer: Mercy Care Medicaid |
$15,824.99
|
| Rate for Payer: NaphCare Correctional Healthcare |
$15,824.99
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$10,090.34
|
|
|
Service Code
|
APR-DRG 8421
|
| Hospital Charge Code |
APRDRG8423
|
| Min. Negotiated Rate |
$10,090.34 |
| Max. Negotiated Rate |
$10,090.34 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$10,090.34
|
| Rate for Payer: Mercy Care Medicaid |
$10,090.34
|
| Rate for Payer: NaphCare Correctional Healthcare |
$10,090.34
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$71,693.60
|
|
|
Service Code
|
APR-DRG 8424
|
| Hospital Charge Code |
APRDRG8422
|
| Min. Negotiated Rate |
$71,693.60 |
| Max. Negotiated Rate |
$71,693.60 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$71,693.60
|
| Rate for Payer: Mercy Care Medicaid |
$71,693.60
|
| Rate for Payer: NaphCare Correctional Healthcare |
$71,693.60
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$71,693.60
|
|
|
Service Code
|
APR-DRG 8424
|
| Hospital Charge Code |
APRDRG8424
|
| Min. Negotiated Rate |
$71,693.60 |
| Max. Negotiated Rate |
$71,693.60 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$71,693.60
|
| Rate for Payer: Mercy Care Medicaid |
$71,693.60
|
| Rate for Payer: NaphCare Correctional Healthcare |
$71,693.60
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$10,090.34
|
|
|
Service Code
|
APR-DRG 8421
|
| Hospital Charge Code |
APRDRG8421
|
| Min. Negotiated Rate |
$10,090.34 |
| Max. Negotiated Rate |
$10,090.34 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$10,090.34
|
| Rate for Payer: Mercy Care Medicaid |
$10,090.34
|
| Rate for Payer: NaphCare Correctional Healthcare |
$10,090.34
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$29,190.87
|
|
|
Service Code
|
APR-DRG 8423
|
| Hospital Charge Code |
APRDRG8424
|
| Min. Negotiated Rate |
$29,190.87 |
| Max. Negotiated Rate |
$29,190.87 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$29,190.87
|
| Rate for Payer: Mercy Care Medicaid |
$29,190.87
|
| Rate for Payer: NaphCare Correctional Healthcare |
$29,190.87
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$15,824.99
|
|
|
Service Code
|
APR-DRG 8422
|
| Hospital Charge Code |
APRDRG8422
|
| Min. Negotiated Rate |
$15,824.99 |
| Max. Negotiated Rate |
$15,824.99 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$15,824.99
|
| Rate for Payer: Mercy Care Medicaid |
$15,824.99
|
| Rate for Payer: NaphCare Correctional Healthcare |
$15,824.99
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$10,090.34
|
|
|
Service Code
|
APR-DRG 8421
|
| Hospital Charge Code |
APRDRG8424
|
| Min. Negotiated Rate |
$10,090.34 |
| Max. Negotiated Rate |
$10,090.34 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$10,090.34
|
| Rate for Payer: Mercy Care Medicaid |
$10,090.34
|
| Rate for Payer: NaphCare Correctional Healthcare |
$10,090.34
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$71,693.60
|
|
|
Service Code
|
APR-DRG 8424
|
| Hospital Charge Code |
APRDRG8423
|
| Min. Negotiated Rate |
$71,693.60 |
| Max. Negotiated Rate |
$71,693.60 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$71,693.60
|
| Rate for Payer: Mercy Care Medicaid |
$71,693.60
|
| Rate for Payer: NaphCare Correctional Healthcare |
$71,693.60
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$10,090.34
|
|
|
Service Code
|
APR-DRG 8421
|
| Hospital Charge Code |
APRDRG8422
|
| Min. Negotiated Rate |
$10,090.34 |
| Max. Negotiated Rate |
$10,090.34 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$10,090.34
|
| Rate for Payer: Mercy Care Medicaid |
$10,090.34
|
| Rate for Payer: NaphCare Correctional Healthcare |
$10,090.34
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$15,824.99
|
|
|
Service Code
|
APR-DRG 8422
|
| Hospital Charge Code |
APRDRG8424
|
| Min. Negotiated Rate |
$15,824.99 |
| Max. Negotiated Rate |
$15,824.99 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$15,824.99
|
| Rate for Payer: Mercy Care Medicaid |
$15,824.99
|
| Rate for Payer: NaphCare Correctional Healthcare |
$15,824.99
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$15,824.99
|
|
|
Service Code
|
APR-DRG 8422
|
| Hospital Charge Code |
APRDRG8421
|
| Min. Negotiated Rate |
$15,824.99 |
| Max. Negotiated Rate |
$15,824.99 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$15,824.99
|
| Rate for Payer: Mercy Care Medicaid |
$15,824.99
|
| Rate for Payer: NaphCare Correctional Healthcare |
$15,824.99
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$29,190.87
|
|
|
Service Code
|
APR-DRG 8423
|
| Hospital Charge Code |
APRDRG8422
|
| Min. Negotiated Rate |
$29,190.87 |
| Max. Negotiated Rate |
$29,190.87 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$29,190.87
|
| Rate for Payer: Mercy Care Medicaid |
$29,190.87
|
| Rate for Payer: NaphCare Correctional Healthcare |
$29,190.87
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$29,190.87
|
|
|
Service Code
|
APR-DRG 8423
|
| Hospital Charge Code |
APRDRG8423
|
| Min. Negotiated Rate |
$29,190.87 |
| Max. Negotiated Rate |
$29,190.87 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$29,190.87
|
| Rate for Payer: Mercy Care Medicaid |
$29,190.87
|
| Rate for Payer: NaphCare Correctional Healthcare |
$29,190.87
|
|
