|
DISP SOFT SNARE
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
22354920
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.76 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna of AZ Commercial |
$44.10
|
| Rate for Payer: Arizona Complete Health Allwell |
$7.84
|
| Rate for Payer: Banner UC Health Medicare |
$7.84
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$33.32
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$7.84
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$7.84
|
| Rate for Payer: Cash Price |
$39.20
|
| Rate for Payer: Cigna of AZ Commercial |
$34.30
|
| Rate for Payer: Devoted Health Medicare |
$8.82
|
| Rate for Payer: Humana of AZ Medicare |
$7.84
|
| Rate for Payer: Southwest Service Administrators UFCW |
$33.32
|
| Rate for Payer: TriWest Medicare |
$7.84
|
| Rate for Payer: United Healthcare Commercial |
$28.03
|
| Rate for Payer: United Healthcare Medicare |
$7.84
|
| Rate for Payer: Veterans Affairs TRICARE |
$7.76
|
|
|
divalproex sodium 125 mg DR Tablet[CQCH]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 62756079688
|
| Hospital Charge Code |
130345400
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of AZ Commercial |
$0.05
|
| 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 |
$0.03
|
| 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 |
$0.04
|
| Rate for Payer: Cigna of AZ Commercial |
$0.03
|
| Rate for Payer: Devoted Health Medicare |
$0.01
|
| Rate for Payer: Humana of AZ Medicare |
$0.01
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.03
|
| Rate for Payer: TriWest Medicare |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
| Rate for Payer: United Healthcare Medicare |
$0.01
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.01
|
|
|
divalproex sodium 125 mg DR Tablet[CQCH]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 62756079688
|
| Hospital Charge Code |
130345400
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of AZ Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
|
|
divalproex sodium 250 mg Oral DR Tab [CQCH]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 68084077601
|
| Hospital Charge Code |
105919506
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of AZ Commercial |
$0.15
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.03
|
| Rate for Payer: Banner UC Health Medicare |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.12
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.03
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.03
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of AZ Commercial |
$0.11
|
| Rate for Payer: Devoted Health Medicare |
$0.03
|
| Rate for Payer: Humana of AZ Medicare |
$0.03
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.12
|
| Rate for Payer: TriWest Medicare |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.10
|
| Rate for Payer: United Healthcare Medicare |
$0.03
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.03
|
|
|
divalproex sodium 250 mg Oral DR Tab [CQCH]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 68084077601
|
| Hospital Charge Code |
105919506
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of AZ Commercial |
$0.15
|
| Rate for Payer: Cash Price |
$0.14
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$6,993.66
|
|
|
Service Code
|
APR-DRG 2443
|
| Hospital Charge Code |
APRDRG2442
|
| Min. Negotiated Rate |
$6,993.66 |
| Max. Negotiated Rate |
$6,993.66 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,993.66
|
| Rate for Payer: Mercy Care Medicaid |
$6,993.66
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,993.66
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$3,380.05
|
|
|
Service Code
|
APR-DRG 2441
|
| Hospital Charge Code |
APRDRG2443
|
| Min. Negotiated Rate |
$3,380.05 |
| Max. Negotiated Rate |
$3,380.05 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,380.05
|
| Rate for Payer: Mercy Care Medicaid |
$3,380.05
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,380.05
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$13,498.44
|
|
|
Service Code
|
APR-DRG 2444
|
| Hospital Charge Code |
APRDRG2442
|
| Min. Negotiated Rate |
$13,498.44 |
| Max. Negotiated Rate |
$13,498.44 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$13,498.44
|
| Rate for Payer: Mercy Care Medicaid |
$13,498.44
|
| Rate for Payer: NaphCare Correctional Healthcare |
$13,498.44
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$4,484.75
|
|
|
Service Code
|
APR-DRG 2442
|
| Hospital Charge Code |
APRDRG2441
|
| Min. Negotiated Rate |
$4,484.75 |
| Max. Negotiated Rate |
$4,484.75 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,484.75
|
| Rate for Payer: Mercy Care Medicaid |
$4,484.75
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,484.75
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$4,484.75
|
|
|
Service Code
|
APR-DRG 2442
|
| Hospital Charge Code |
APRDRG2444
|
| Min. Negotiated Rate |
$4,484.75 |
| Max. Negotiated Rate |
$4,484.75 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,484.75
|
| Rate for Payer: Mercy Care Medicaid |
$4,484.75
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,484.75
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$13,498.44
|
|
|
Service Code
|
APR-DRG 2444
|
| Hospital Charge Code |
APRDRG2444
|
| Min. Negotiated Rate |
$13,498.44 |
| Max. Negotiated Rate |
$13,498.44 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$13,498.44
|
| Rate for Payer: Mercy Care Medicaid |
$13,498.44
|
| Rate for Payer: NaphCare Correctional Healthcare |
$13,498.44
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$3,380.05
|
|
|
Service Code
|
APR-DRG 2441
|
| Hospital Charge Code |
APRDRG2441
|
| Min. Negotiated Rate |
$3,380.05 |
| Max. Negotiated Rate |
$3,380.05 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,380.05
|
| Rate for Payer: Mercy Care Medicaid |
$3,380.05
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,380.05
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$6,993.66
|
|
|
Service Code
|
APR-DRG 2443
|
| Hospital Charge Code |
APRDRG2441
|
| Min. Negotiated Rate |
$6,993.66 |
| Max. Negotiated Rate |
$6,993.66 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,993.66
|
| Rate for Payer: Mercy Care Medicaid |
$6,993.66
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,993.66
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$3,380.05
|
|
|
Service Code
|
APR-DRG 2441
|
| Hospital Charge Code |
APRDRG2442
|
| Min. Negotiated Rate |
$3,380.05 |
| Max. Negotiated Rate |
$3,380.05 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,380.05
|
| Rate for Payer: Mercy Care Medicaid |
$3,380.05
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,380.05
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$13,498.44
|
|
|
Service Code
|
APR-DRG 2444
|
| Hospital Charge Code |
APRDRG2441
|
| Min. Negotiated Rate |
$13,498.44 |
| Max. Negotiated Rate |
$13,498.44 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$13,498.44
|
| Rate for Payer: Mercy Care Medicaid |
$13,498.44
|
| Rate for Payer: NaphCare Correctional Healthcare |
$13,498.44
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$6,993.66
|
|
|
Service Code
|
APR-DRG 2443
|
| Hospital Charge Code |
APRDRG2444
|
| Min. Negotiated Rate |
$6,993.66 |
| Max. Negotiated Rate |
$6,993.66 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,993.66
|
| Rate for Payer: Mercy Care Medicaid |
$6,993.66
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,993.66
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$3,380.05
|
|
|
Service Code
|
APR-DRG 2441
|
| Hospital Charge Code |
APRDRG2444
|
| Min. Negotiated Rate |
$3,380.05 |
| Max. Negotiated Rate |
$3,380.05 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,380.05
|
| Rate for Payer: Mercy Care Medicaid |
$3,380.05
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,380.05
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$6,993.66
|
|
|
Service Code
|
APR-DRG 2443
|
| Hospital Charge Code |
APRDRG2443
|
| Min. Negotiated Rate |
$6,993.66 |
| Max. Negotiated Rate |
$6,993.66 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,993.66
|
| Rate for Payer: Mercy Care Medicaid |
$6,993.66
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,993.66
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$13,498.44
|
|
|
Service Code
|
APR-DRG 2444
|
| Hospital Charge Code |
APRDRG2443
|
| Min. Negotiated Rate |
$13,498.44 |
| Max. Negotiated Rate |
$13,498.44 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$13,498.44
|
| Rate for Payer: Mercy Care Medicaid |
$13,498.44
|
| Rate for Payer: NaphCare Correctional Healthcare |
$13,498.44
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$4,484.75
|
|
|
Service Code
|
APR-DRG 2442
|
| Hospital Charge Code |
APRDRG2442
|
| Min. Negotiated Rate |
$4,484.75 |
| Max. Negotiated Rate |
$4,484.75 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,484.75
|
| Rate for Payer: Mercy Care Medicaid |
$4,484.75
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,484.75
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$4,484.75
|
|
|
Service Code
|
APR-DRG 2442
|
| Hospital Charge Code |
APRDRG2443
|
| Min. Negotiated Rate |
$4,484.75 |
| Max. Negotiated Rate |
$4,484.75 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,484.75
|
| Rate for Payer: Mercy Care Medicaid |
$4,484.75
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,484.75
|
|
|
DMSO intravesical
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
CPT 51700
|
| Hospital Charge Code |
27291812
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$26.61 |
| Max. Negotiated Rate |
$2,671.00 |
| Rate for Payer: Aetna of AZ Commercial |
$151.20
|
| Rate for Payer: Arizona Complete Health Allwell |
$26.88
|
| Rate for Payer: Banner UC Health Medicare |
$30.85
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$114.24
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$47.07
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$26.88
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$26.88
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Cigna of AZ Commercial |
$84.00
|
| Rate for Payer: Devoted Health Medicare |
$30.24
|
| Rate for Payer: Humana of AZ Medicare |
$26.88
|
| Rate for Payer: Mercy Care Medicaid |
$47.07
|
| Rate for Payer: NaphCare Correctional Healthcare |
$30.85
|
| Rate for Payer: Seven Corners Travel Insurance |
$386.58
|
| Rate for Payer: Southwest Service Administrators UFCW |
$114.24
|
| Rate for Payer: TriWest Medicare |
$26.88
|
| Rate for Payer: United Healthcare Commercial |
$2,671.00
|
| Rate for Payer: United Healthcare Medicare |
$26.88
|
| Rate for Payer: Veterans Affairs TRICARE |
$26.61
|
|
|
DMSO intravesical
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
CPT 51700
|
| Hospital Charge Code |
27291812
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$151.20 |
| Max. Negotiated Rate |
$151.20 |
| Rate for Payer: Aetna of AZ Commercial |
$151.20
|
| Rate for Payer: Cash Price |
$134.40
|
|
|
DOBUTamine 12.5 mg/mL Sol[CQCH]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
141138221
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of AZ Commercial |
$0.23
|
| Rate for Payer: Cash Price |
$0.20
|
|
|
DOBUTamine 12.5 mg/mL Sol[CQCH]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
141138221
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of AZ Commercial |
$0.23
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.04
|
| Rate for Payer: Banner UC Health Medicare |
$0.04
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.17
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.04
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.04
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of AZ Commercial |
$0.16
|
| Rate for Payer: Devoted Health Medicare |
$0.05
|
| Rate for Payer: Humana of AZ Medicare |
$0.04
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.17
|
| Rate for Payer: TriWest Medicare |
$0.04
|
| Rate for Payer: United Healthcare Commercial |
$0.14
|
| Rate for Payer: United Healthcare Medicare |
$0.04
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.04
|
|
