|
diphenhydrAMINE 50 mg/mL Inj Sol [CQCH]
|
Facility
|
IP
|
$0.81
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
105919362
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Aetna of AZ Commercial |
$0.73
|
| Rate for Payer: Cash Price |
$0.65
|
|
|
diphenhydrAMINE 50 mg/mL Inj Sol [CQCH]
|
Facility
|
OP
|
$0.81
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
105919362
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Aetna of AZ Commercial |
$0.73
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.13
|
| Rate for Payer: Banner UC Health Medicare |
$0.13
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.55
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.13
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cigna of AZ Commercial |
$0.53
|
| Rate for Payer: Devoted Health Medicare |
$0.15
|
| Rate for Payer: Humana of AZ Medicare |
$0.13
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.55
|
| Rate for Payer: TriWest Medicare |
$0.13
|
| Rate for Payer: United Healthcare Commercial |
$0.46
|
| Rate for Payer: United Healthcare Medicare |
$0.13
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.13
|
|
|
Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine,
|
Facility
|
IP
|
$203.00
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
1787562
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$182.70 |
| Max. Negotiated Rate |
$182.70 |
| Rate for Payer: Aetna of AZ Commercial |
$182.70
|
| Rate for Payer: Cash Price |
$162.40
|
|
|
Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine,
|
Facility
|
OP
|
$203.00
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
1787562
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.16 |
| Max. Negotiated Rate |
$182.70 |
| Rate for Payer: Aetna of AZ Commercial |
$182.70
|
| Rate for Payer: Arizona Complete Health Allwell |
$32.48
|
| Rate for Payer: Banner UC Health Medicare |
$32.48
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$138.04
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$32.48
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$32.48
|
| Rate for Payer: Cash Price |
$162.40
|
| Rate for Payer: Cigna of AZ Commercial |
$142.10
|
| Rate for Payer: Devoted Health Medicare |
$36.54
|
| Rate for Payer: Humana of AZ Medicare |
$32.48
|
| Rate for Payer: Southwest Service Administrators UFCW |
$138.04
|
| Rate for Payer: TriWest Medicare |
$32.48
|
| Rate for Payer: United Healthcare Commercial |
$116.12
|
| Rate for Payer: United Healthcare Medicare |
$32.48
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$38.57
|
| Rate for Payer: Veterans Affairs TRICARE |
$32.16
|
|
|
Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza
|
Facility
|
IP
|
$195.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
1229742
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$175.50 |
| Max. Negotiated Rate |
$175.50 |
| Rate for Payer: Aetna of AZ Commercial |
$175.50
|
| Rate for Payer: Cash Price |
$156.00
|
|
|
Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza
|
Facility
|
OP
|
$195.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
1229742
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.89 |
| Max. Negotiated Rate |
$175.50 |
| Rate for Payer: Aetna of AZ Commercial |
$175.50
|
| Rate for Payer: Arizona Complete Health Allwell |
$31.20
|
| Rate for Payer: Banner UC Health Medicare |
$31.20
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$132.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$31.20
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$31.20
|
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cigna of AZ Commercial |
$136.50
|
| Rate for Payer: Devoted Health Medicare |
$35.10
|
| Rate for Payer: Humana of AZ Medicare |
$31.20
|
| Rate for Payer: Southwest Service Administrators UFCW |
$132.60
|
| Rate for Payer: TriWest Medicare |
$31.20
|
| Rate for Payer: United Healthcare Commercial |
$111.54
|
| Rate for Payer: United Healthcare Medicare |
$31.20
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$37.05
|
| Rate for Payer: Veterans Affairs TRICARE |
$30.89
|
|
|
Diphth/HepB/Pertussis,Acel/Polio/Tetanus Vaccine POC
|
Facility
|
OP
|
$226.00
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
667690
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.80 |
| Max. Negotiated Rate |
$203.40 |
| Rate for Payer: Aetna of AZ Commercial |
$203.40
|
| Rate for Payer: Arizona Complete Health Allwell |
$36.16
|
| Rate for Payer: Banner UC Health Medicare |
$36.16
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$153.68
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$36.16
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$36.16
|
| Rate for Payer: Cash Price |
$180.80
|
| Rate for Payer: Cigna of AZ Commercial |
$158.20
|
| Rate for Payer: Devoted Health Medicare |
$40.68
|
| Rate for Payer: Humana of AZ Medicare |
$36.16
|
| Rate for Payer: Southwest Service Administrators UFCW |
$153.68
|
| Rate for Payer: TriWest Medicare |
$36.16
|
| Rate for Payer: United Healthcare Commercial |
$129.27
|
| Rate for Payer: United Healthcare Medicare |
$36.16
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$42.94
|
| Rate for Payer: Veterans Affairs TRICARE |
$35.80
|
|
|
Diphth/HepB/Pertussis,Acel/Polio/Tetanus Vaccine POC
|
Facility
|
IP
|
$226.00
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
667690
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$203.40 |
| Max. Negotiated Rate |
$203.40 |
| Rate for Payer: Aetna of AZ Commercial |
$203.40
|
| Rate for Payer: Cash Price |
$180.80
|
|
|
Direct LDL
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
CPT 83721
|
| Hospital Charge Code |
1735730
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.22 |
| Max. Negotiated Rate |
$142.20 |
| Rate for Payer: Aetna of AZ Commercial |
$142.20
|
| Rate for Payer: Arizona Complete Health Allwell |
$25.28
|
| Rate for Payer: Banner UC Health Medicare |
$25.28
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$107.44
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$25.28
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$25.28
|
| Rate for Payer: Cash Price |
$126.40
|
| Rate for Payer: Cash Price |
$126.40
|
| Rate for Payer: Cigna of AZ Commercial |
$102.70
|
| Rate for Payer: Devoted Health Medicare |
$28.44
|
| Rate for Payer: Humana of AZ Medicare |
$25.28
|
| Rate for Payer: Seven Corners Travel Insurance |
$15.22
|
| Rate for Payer: Southwest Service Administrators UFCW |
$107.44
|
| Rate for Payer: TriWest Medicare |
$25.28
|
| Rate for Payer: United Healthcare Commercial |
$90.38
|
| Rate for Payer: United Healthcare Medicare |
$25.28
|
| Rate for Payer: Veterans Affairs TRICARE |
$25.03
|
|
|
Direct LDL
|
Facility
|
IP
|
$158.00
|
|
|
Service Code
|
CPT 83721
|
| Hospital Charge Code |
1735730
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$142.20 |
| Max. Negotiated Rate |
$142.20 |
| Rate for Payer: Aetna of AZ Commercial |
$142.20
|
| Rate for Payer: Cash Price |
$126.40
|
|
|
Disorders Of Gallbladder And Biliary Tract
|
Facility
|
IP
|
$15,486.91
|
|
|
Service Code
|
APR-DRG 2844
|
| Hospital Charge Code |
APRDRG2843
|
| Min. Negotiated Rate |
$15,486.91 |
| Max. Negotiated Rate |
$15,486.91 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$15,486.91
|
| Rate for Payer: Mercy Care Medicaid |
$15,486.91
|
| Rate for Payer: NaphCare Correctional Healthcare |
$15,486.91
|
|
|
Disorders Of Gallbladder And Biliary Tract
|
Facility
|
IP
|
$5,649.08
|
|
|
Service Code
|
APR-DRG 2842
|
| Hospital Charge Code |
APRDRG2841
|
| Min. Negotiated Rate |
$5,649.08 |
| Max. Negotiated Rate |
$5,649.08 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,649.08
|
| Rate for Payer: Mercy Care Medicaid |
$5,649.08
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,649.08
|
|
|
Disorders Of Gallbladder And Biliary Tract
|
Facility
|
IP
|
$8,132.03
|
|
|
Service Code
|
APR-DRG 2843
|
| Hospital Charge Code |
APRDRG2841
|
| Min. Negotiated Rate |
$8,132.03 |
| Max. Negotiated Rate |
$8,132.03 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$8,132.03
|
| Rate for Payer: Mercy Care Medicaid |
$8,132.03
|
| Rate for Payer: NaphCare Correctional Healthcare |
$8,132.03
|
|
|
Disorders Of Gallbladder And Biliary Tract
|
Facility
|
IP
|
$4,418.12
|
|
|
Service Code
|
APR-DRG 2841
|
| Hospital Charge Code |
APRDRG2842
|
| Min. Negotiated Rate |
$4,418.12 |
| Max. Negotiated Rate |
$4,418.12 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,418.12
|
| Rate for Payer: Mercy Care Medicaid |
$4,418.12
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,418.12
|
|
|
Disorders Of Gallbladder And Biliary Tract
|
Facility
|
IP
|
$15,486.91
|
|
|
Service Code
|
APR-DRG 2844
|
| Hospital Charge Code |
APRDRG2844
|
| Min. Negotiated Rate |
$15,486.91 |
| Max. Negotiated Rate |
$15,486.91 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$15,486.91
|
| Rate for Payer: Mercy Care Medicaid |
$15,486.91
|
| Rate for Payer: NaphCare Correctional Healthcare |
$15,486.91
|
|
|
Disorders Of Gallbladder And Biliary Tract
|
Facility
|
IP
|
$8,132.03
|
|
|
Service Code
|
APR-DRG 2843
|
| Hospital Charge Code |
APRDRG2843
|
| Min. Negotiated Rate |
$8,132.03 |
| Max. Negotiated Rate |
$8,132.03 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$8,132.03
|
| Rate for Payer: Mercy Care Medicaid |
$8,132.03
|
| Rate for Payer: NaphCare Correctional Healthcare |
$8,132.03
|
|
|
Disorders Of Gallbladder And Biliary Tract
|
Facility
|
IP
|
$5,649.08
|
|
|
Service Code
|
APR-DRG 2842
|
| Hospital Charge Code |
APRDRG2844
|
| Min. Negotiated Rate |
$5,649.08 |
| Max. Negotiated Rate |
$5,649.08 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,649.08
|
| Rate for Payer: Mercy Care Medicaid |
$5,649.08
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,649.08
|
|
|
Disorders Of Gallbladder And Biliary Tract
|
Facility
|
IP
|
$4,418.12
|
|
|
Service Code
|
APR-DRG 2841
|
| Hospital Charge Code |
APRDRG2843
|
| Min. Negotiated Rate |
$4,418.12 |
| Max. Negotiated Rate |
$4,418.12 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,418.12
|
| Rate for Payer: Mercy Care Medicaid |
$4,418.12
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,418.12
|
|
|
Disorders Of Gallbladder And Biliary Tract
|
Facility
|
IP
|
$4,418.12
|
|
|
Service Code
|
APR-DRG 2841
|
| Hospital Charge Code |
APRDRG2844
|
| Min. Negotiated Rate |
$4,418.12 |
| Max. Negotiated Rate |
$4,418.12 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,418.12
|
| Rate for Payer: Mercy Care Medicaid |
$4,418.12
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,418.12
|
|
|
Disorders Of Gallbladder And Biliary Tract
|
Facility
|
IP
|
$5,649.08
|
|
|
Service Code
|
APR-DRG 2842
|
| Hospital Charge Code |
APRDRG2843
|
| Min. Negotiated Rate |
$5,649.08 |
| Max. Negotiated Rate |
$5,649.08 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,649.08
|
| Rate for Payer: Mercy Care Medicaid |
$5,649.08
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,649.08
|
|
|
Disorders Of Gallbladder And Biliary Tract
|
Facility
|
IP
|
$15,486.91
|
|
|
Service Code
|
APR-DRG 2844
|
| Hospital Charge Code |
APRDRG2841
|
| Min. Negotiated Rate |
$15,486.91 |
| Max. Negotiated Rate |
$15,486.91 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$15,486.91
|
| Rate for Payer: Mercy Care Medicaid |
$15,486.91
|
| Rate for Payer: NaphCare Correctional Healthcare |
$15,486.91
|
|
|
Disorders Of Gallbladder And Biliary Tract
|
Facility
|
IP
|
$5,649.08
|
|
|
Service Code
|
APR-DRG 2842
|
| Hospital Charge Code |
APRDRG2842
|
| Min. Negotiated Rate |
$5,649.08 |
| Max. Negotiated Rate |
$5,649.08 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,649.08
|
| Rate for Payer: Mercy Care Medicaid |
$5,649.08
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,649.08
|
|
|
Disorders Of Gallbladder And Biliary Tract
|
Facility
|
IP
|
$8,132.03
|
|
|
Service Code
|
APR-DRG 2843
|
| Hospital Charge Code |
APRDRG2842
|
| Min. Negotiated Rate |
$8,132.03 |
| Max. Negotiated Rate |
$8,132.03 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$8,132.03
|
| Rate for Payer: Mercy Care Medicaid |
$8,132.03
|
| Rate for Payer: NaphCare Correctional Healthcare |
$8,132.03
|
|
|
Disorders Of Gallbladder And Biliary Tract
|
Facility
|
IP
|
$15,486.91
|
|
|
Service Code
|
APR-DRG 2844
|
| Hospital Charge Code |
APRDRG2842
|
| Min. Negotiated Rate |
$15,486.91 |
| Max. Negotiated Rate |
$15,486.91 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$15,486.91
|
| Rate for Payer: Mercy Care Medicaid |
$15,486.91
|
| Rate for Payer: NaphCare Correctional Healthcare |
$15,486.91
|
|
|
Disorders Of Gallbladder And Biliary Tract
|
Facility
|
IP
|
$8,132.03
|
|
|
Service Code
|
APR-DRG 2843
|
| Hospital Charge Code |
APRDRG2844
|
| Min. Negotiated Rate |
$8,132.03 |
| Max. Negotiated Rate |
$8,132.03 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$8,132.03
|
| Rate for Payer: Mercy Care Medicaid |
$8,132.03
|
| Rate for Payer: NaphCare Correctional Healthcare |
$8,132.03
|
|
