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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

DENTURE ADHESIVE

Facility

IP

$14.00

Hospital Charge Code	22781968
Hospital Revenue Code	272
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$12.60
Rate for Payer: Aetna of AZ Commercial	$12.60
Rate for Payer: Cash Price	$11.20

DEPO-Medrol 40 mg/1 mL Inj Susp [CQCH]

Facility

IP

$6.50

Service Code	HCPCS J1030
Hospital Charge Code	105931516
Hospital Revenue Code	250
Min. Negotiated Rate	$5.85
Max. Negotiated Rate	$5.85
Rate for Payer: Aetna of AZ Commercial	$5.85
Rate for Payer: Cash Price	$5.20

DEPO-Medrol 40 mg/1 mL Inj Susp [CQCH]

Facility

OP

$6.50

Service Code	HCPCS J1030
Hospital Charge Code	105931516
Hospital Revenue Code	250
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$5.85
Rate for Payer: Aetna of AZ Commercial	$5.85
Rate for Payer: Arizona Complete Health Allwell	$1.04
Rate for Payer: Banner UC Health Medicare	$1.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$4.42
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.04
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna of AZ Commercial	$4.22
Rate for Payer: Devoted Health Medicare	$1.17
Rate for Payer: Humana of AZ Medicare	$1.04
Rate for Payer: Southwest Service Administrators UFCW	$4.42
Rate for Payer: TriWest Medicare	$1.04
Rate for Payer: United Healthcare Commercial	$3.72
Rate for Payer: United Healthcare Medicare	$1.04
Rate for Payer: Veterans Affairs TRICARE	$1.03

Depression Except Major Depressive Disorder

Facility

IP

$2,042.48

Service Code	APR-DRG 7541
Hospital Charge Code	APRDRG7544
Min. Negotiated Rate	$2,042.48
Max. Negotiated Rate	$2,042.48
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$2,042.48
Rate for Payer: Mercy Care Medicaid	$2,042.48
Rate for Payer: NaphCare Correctional Healthcare	$2,042.48

Depression Except Major Depressive Disorder

Facility

IP

$2,837.16

Service Code	APR-DRG 7542
Hospital Charge Code	APRDRG7541
Min. Negotiated Rate	$2,837.16
Max. Negotiated Rate	$2,837.16
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$2,837.16
Rate for Payer: Mercy Care Medicaid	$2,837.16
Rate for Payer: NaphCare Correctional Healthcare	$2,837.16

Depression Except Major Depressive Disorder

Facility

IP

$2,042.48

Service Code	APR-DRG 7541
Hospital Charge Code	APRDRG7541
Min. Negotiated Rate	$2,042.48
Max. Negotiated Rate	$2,042.48
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$2,042.48
Rate for Payer: Mercy Care Medicaid	$2,042.48
Rate for Payer: NaphCare Correctional Healthcare	$2,042.48

Depression Except Major Depressive Disorder

Facility

IP

$10,887.13

Service Code	APR-DRG 7544
Hospital Charge Code	APRDRG7542
Min. Negotiated Rate	$10,887.13
Max. Negotiated Rate	$10,887.13
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$10,887.13
Rate for Payer: Mercy Care Medicaid	$10,887.13
Rate for Payer: NaphCare Correctional Healthcare	$10,887.13

Depression Except Major Depressive Disorder

Facility

IP

$2,042.48

Service Code	APR-DRG 7541
Hospital Charge Code	APRDRG7543
Min. Negotiated Rate	$2,042.48
Max. Negotiated Rate	$2,042.48
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$2,042.48
Rate for Payer: Mercy Care Medicaid	$2,042.48
Rate for Payer: NaphCare Correctional Healthcare	$2,042.48

Depression Except Major Depressive Disorder

Facility

IP

$10,887.13

Service Code	APR-DRG 7544
Hospital Charge Code	APRDRG7544
Min. Negotiated Rate	$10,887.13
Max. Negotiated Rate	$10,887.13
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$10,887.13
Rate for Payer: Mercy Care Medicaid	$10,887.13
Rate for Payer: NaphCare Correctional Healthcare	$10,887.13

Depression Except Major Depressive Disorder

Facility

IP

$2,837.16

Service Code	APR-DRG 7542
Hospital Charge Code	APRDRG7542
Min. Negotiated Rate	$2,837.16
Max. Negotiated Rate	$2,837.16
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$2,837.16
Rate for Payer: Mercy Care Medicaid	$2,837.16
Rate for Payer: NaphCare Correctional Healthcare	$2,837.16

Depression Except Major Depressive Disorder

Facility

IP

$10,887.13

Service Code	APR-DRG 7544
Hospital Charge Code	APRDRG7543
Min. Negotiated Rate	$10,887.13
Max. Negotiated Rate	$10,887.13
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$10,887.13
Rate for Payer: Mercy Care Medicaid	$10,887.13
Rate for Payer: NaphCare Correctional Healthcare	$10,887.13

Depression Except Major Depressive Disorder

Facility

IP

$10,887.13

Service Code	APR-DRG 7544
Hospital Charge Code	APRDRG7541
Min. Negotiated Rate	$10,887.13
Max. Negotiated Rate	$10,887.13
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$10,887.13
Rate for Payer: Mercy Care Medicaid	$10,887.13
Rate for Payer: NaphCare Correctional Healthcare	$10,887.13

Depression Except Major Depressive Disorder

Facility

IP

$2,837.16

Service Code	APR-DRG 7542
Hospital Charge Code	APRDRG7543
Min. Negotiated Rate	$2,837.16
Max. Negotiated Rate	$2,837.16
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$2,837.16
Rate for Payer: Mercy Care Medicaid	$2,837.16
Rate for Payer: NaphCare Correctional Healthcare	$2,837.16

Depression Except Major Depressive Disorder

Facility

IP

$4,831.94

Service Code	APR-DRG 7543
Hospital Charge Code	APRDRG7543
Min. Negotiated Rate	$4,831.94
Max. Negotiated Rate	$4,831.94
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$4,831.94
Rate for Payer: Mercy Care Medicaid	$4,831.94
Rate for Payer: NaphCare Correctional Healthcare	$4,831.94

Depression Except Major Depressive Disorder

Facility

IP

$4,831.94

Service Code	APR-DRG 7543
Hospital Charge Code	APRDRG7542
Min. Negotiated Rate	$4,831.94
Max. Negotiated Rate	$4,831.94
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$4,831.94
Rate for Payer: Mercy Care Medicaid	$4,831.94
Rate for Payer: NaphCare Correctional Healthcare	$4,831.94

Depression Except Major Depressive Disorder

Facility

IP

$2,837.16

Service Code	APR-DRG 7542
Hospital Charge Code	APRDRG7544
Min. Negotiated Rate	$2,837.16
Max. Negotiated Rate	$2,837.16
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$2,837.16
Rate for Payer: Mercy Care Medicaid	$2,837.16
Rate for Payer: NaphCare Correctional Healthcare	$2,837.16

Depression Except Major Depressive Disorder

Facility

IP

$4,831.94

Service Code	APR-DRG 7543
Hospital Charge Code	APRDRG7541
Min. Negotiated Rate	$4,831.94
Max. Negotiated Rate	$4,831.94
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$4,831.94
Rate for Payer: Mercy Care Medicaid	$4,831.94
Rate for Payer: NaphCare Correctional Healthcare	$4,831.94

Depression Except Major Depressive Disorder

Facility

IP

$4,831.94

Service Code	APR-DRG 7543
Hospital Charge Code	APRDRG7544
Min. Negotiated Rate	$4,831.94
Max. Negotiated Rate	$4,831.94
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$4,831.94
Rate for Payer: Mercy Care Medicaid	$4,831.94
Rate for Payer: NaphCare Correctional Healthcare	$4,831.94

Depression Except Major Depressive Disorder

Facility

IP

$2,042.48

Service Code	APR-DRG 7541
Hospital Charge Code	APRDRG7542
Min. Negotiated Rate	$2,042.48
Max. Negotiated Rate	$2,042.48
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$2,042.48
Rate for Payer: Mercy Care Medicaid	$2,042.48
Rate for Payer: NaphCare Correctional Healthcare	$2,042.48

DEPRESSIVE NEUROSES

Facility

IP

$12,277.77

Service Code	MSDRG 881
Min. Negotiated Rate	$12,277.77
Max. Negotiated Rate	$12,277.77
Rate for Payer: Seven Corners Travel Insurance	$12,277.77

DERMABOND PROPEN

Facility

IP

$105.00

Hospital Charge Code	22355194
Hospital Revenue Code	270
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$94.50
Rate for Payer: Aetna of AZ Commercial	$94.50
Rate for Payer: Cash Price	$84.00

DERMABOND PROPEN

Facility

OP

$105.00

Hospital Charge Code	22355194
Hospital Revenue Code	270
Min. Negotiated Rate	$16.63
Max. Negotiated Rate	$94.50
Rate for Payer: Aetna of AZ Commercial	$94.50
Rate for Payer: Arizona Complete Health Allwell	$16.80
Rate for Payer: Banner UC Health Medicare	$16.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$71.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.80
Rate for Payer: Cash Price	$84.00
Rate for Payer: Cigna of AZ Commercial	$73.50
Rate for Payer: Devoted Health Medicare	$18.90
Rate for Payer: Humana of AZ Medicare	$16.80
Rate for Payer: Southwest Service Administrators UFCW	$71.40
Rate for Payer: TriWest Medicare	$16.80
Rate for Payer: United Healthcare Commercial	$60.06
Rate for Payer: United Healthcare Medicare	$16.80
Rate for Payer: Veterans Affairs TRICARE	$16.63

DERMAGRAFT

Facility

IP

$309.00

Service Code	HCPCS Q4106
Hospital Charge Code	24358082
Hospital Revenue Code	636
Min. Negotiated Rate	$278.10
Max. Negotiated Rate	$278.10
Rate for Payer: Aetna of AZ Commercial	$278.10
Rate for Payer: Cash Price	$247.20

DERMAGRAFT

Facility

OP

$309.00

Service Code	HCPCS Q4106
Hospital Charge Code	24358082
Hospital Revenue Code	636
Min. Negotiated Rate	$48.95
Max. Negotiated Rate	$278.10
Rate for Payer: Aetna of AZ Commercial	$278.10
Rate for Payer: Arizona Complete Health Allwell	$49.44
Rate for Payer: Banner UC Health Medicare	$49.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$210.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$49.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$49.44
Rate for Payer: Cash Price	$247.20
Rate for Payer: Cigna of AZ Commercial	$216.30
Rate for Payer: Devoted Health Medicare	$55.62
Rate for Payer: Humana of AZ Medicare	$49.44
Rate for Payer: Southwest Service Administrators UFCW	$210.12
Rate for Payer: TriWest Medicare	$49.44
Rate for Payer: United Healthcare Commercial	$176.75
Rate for Payer: United Healthcare Medicare	$49.44
Rate for Payer: United Healthcare New Mexico Commercial	$58.71
Rate for Payer: Veterans Affairs TRICARE	$48.95

DERMAGRAFT, PER SQUARE CENTIMETER

Facility

IP

$170.00

Service Code	HCPCS Q4106
Hospital Charge Code	24049286
Hospital Revenue Code	636
Min. Negotiated Rate	$153.00
Max. Negotiated Rate	$153.00
Rate for Payer: Aetna of AZ Commercial	$153.00
Rate for Payer: Cash Price	$136.00

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