|
Eye stream-Ophth irrigation [CQCH]
|
Facility
|
OP
|
$17.53
|
|
|
Service Code
|
NDC 65053001
|
| Hospital Charge Code |
105934956
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$15.78 |
| Rate for Payer: Aetna of AZ Commercial |
$15.78
|
| Rate for Payer: Arizona Complete Health Allwell |
$2.80
|
| Rate for Payer: Banner UC Health Medicare |
$2.80
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$11.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$2.80
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$2.80
|
| Rate for Payer: Cash Price |
$14.02
|
| Rate for Payer: Cigna of AZ Commercial |
$11.39
|
| Rate for Payer: Devoted Health Medicare |
$3.16
|
| Rate for Payer: Humana of AZ Medicare |
$2.80
|
| Rate for Payer: Southwest Service Administrators UFCW |
$11.92
|
| Rate for Payer: TriWest Medicare |
$2.80
|
| Rate for Payer: United Healthcare Commercial |
$10.03
|
| Rate for Payer: United Healthcare Medicare |
$2.80
|
| Rate for Payer: Veterans Affairs TRICARE |
$2.78
|
|
|
Eye stream-Ophth irrigation [CQCH]
|
Facility
|
IP
|
$17.53
|
|
|
Service Code
|
NDC 65053001
|
| Hospital Charge Code |
105934956
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$15.78 |
| Max. Negotiated Rate |
$15.78 |
| Rate for Payer: Aetna of AZ Commercial |
$15.78
|
| Rate for Payer: Cash Price |
$14.02
|
|
|
EZDILATE BALLOON DILATOR 18-20
|
Facility
|
OP
|
$1,205.00
|
|
| Hospital Charge Code |
27387880
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$190.87 |
| Max. Negotiated Rate |
$1,084.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,084.50
|
| Rate for Payer: Arizona Complete Health Allwell |
$192.80
|
| Rate for Payer: Banner UC Health Medicare |
$192.80
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$819.40
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$192.80
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$192.80
|
| Rate for Payer: Cash Price |
$964.00
|
| Rate for Payer: Cigna of AZ Commercial |
$843.50
|
| Rate for Payer: Devoted Health Medicare |
$216.90
|
| Rate for Payer: Humana of AZ Medicare |
$192.80
|
| Rate for Payer: Southwest Service Administrators UFCW |
$819.40
|
| Rate for Payer: TriWest Medicare |
$192.80
|
| Rate for Payer: United Healthcare Commercial |
$689.26
|
| Rate for Payer: United Healthcare Medicare |
$192.80
|
| Rate for Payer: Veterans Affairs TRICARE |
$190.87
|
|
|
EZDILATE BALLOON DILATOR 18-20
|
Facility
|
IP
|
$1,205.00
|
|
| Hospital Charge Code |
27387880
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,084.50 |
| Max. Negotiated Rate |
$1,084.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,084.50
|
| Rate for Payer: Cash Price |
$964.00
|
|
|
EZDILATE ENDO BALLONE DILATOR 13.5MM TO 15.5MM
|
Facility
|
IP
|
$1,395.00
|
|
| Hospital Charge Code |
28042254
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,255.50 |
| Max. Negotiated Rate |
$1,255.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,255.50
|
| Rate for Payer: Cash Price |
$1,116.00
|
|
|
EZDILATE ENDO BALLONE DILATOR 13.5MM TO 15.5MM
|
Facility
|
OP
|
$1,395.00
|
|
| Hospital Charge Code |
28042254
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$220.97 |
| Max. Negotiated Rate |
$1,255.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,255.50
|
| Rate for Payer: Arizona Complete Health Allwell |
$223.20
|
| Rate for Payer: Banner UC Health Medicare |
$223.20
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$948.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$223.20
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$223.20
|
| Rate for Payer: Cash Price |
$1,116.00
|
| Rate for Payer: Cigna of AZ Commercial |
$976.50
|
| Rate for Payer: Devoted Health Medicare |
$251.10
|
| Rate for Payer: Humana of AZ Medicare |
$223.20
|
| Rate for Payer: Southwest Service Administrators UFCW |
$948.60
|
| Rate for Payer: TriWest Medicare |
$223.20
|
| Rate for Payer: United Healthcare Commercial |
$797.94
|
| Rate for Payer: United Healthcare Medicare |
$223.20
|
| Rate for Payer: Veterans Affairs TRICARE |
$220.97
|
|
|
EZDILATE ENDO BALLOON DILATOR 16MM TO 18MM
|
Facility
|
OP
|
$1,395.00
|
|
| Hospital Charge Code |
28042256
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$220.97 |
| Max. Negotiated Rate |
$1,255.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,255.50
|
| Rate for Payer: Arizona Complete Health Allwell |
$223.20
|
| Rate for Payer: Banner UC Health Medicare |
$223.20
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$948.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$223.20
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$223.20
|
| Rate for Payer: Cash Price |
$1,116.00
|
| Rate for Payer: Cigna of AZ Commercial |
$976.50
|
| Rate for Payer: Devoted Health Medicare |
$251.10
|
| Rate for Payer: Humana of AZ Medicare |
$223.20
|
| Rate for Payer: Southwest Service Administrators UFCW |
$948.60
|
| Rate for Payer: TriWest Medicare |
$223.20
|
| Rate for Payer: United Healthcare Commercial |
$797.94
|
| Rate for Payer: United Healthcare Medicare |
$223.20
|
| Rate for Payer: Veterans Affairs TRICARE |
$220.97
|
|
|
EZDILATE ENDO BALLOON DILATOR 16MM TO 18MM
|
Facility
|
IP
|
$1,395.00
|
|
| Hospital Charge Code |
28042256
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,255.50 |
| Max. Negotiated Rate |
$1,255.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,255.50
|
| Rate for Payer: Cash Price |
$1,116.00
|
|
|
EZ IO STABILIZER
|
Facility
|
IP
|
$100.00
|
|
| Hospital Charge Code |
24395365
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$90.00 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Aetna of AZ Commercial |
$90.00
|
| Rate for Payer: Cash Price |
$80.00
|
|
|
EZ IO STABILIZER
|
Facility
|
OP
|
$100.00
|
|
| Hospital Charge Code |
24395365
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.84 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Aetna of AZ Commercial |
$90.00
|
| Rate for Payer: Arizona Complete Health Allwell |
$16.00
|
| Rate for Payer: Banner UC Health Medicare |
$16.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$68.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$16.00
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$16.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cigna of AZ Commercial |
$70.00
|
| Rate for Payer: Devoted Health Medicare |
$18.00
|
| Rate for Payer: Humana of AZ Medicare |
$16.00
|
| Rate for Payer: Southwest Service Administrators UFCW |
$68.00
|
| Rate for Payer: TriWest Medicare |
$16.00
|
| Rate for Payer: United Healthcare Commercial |
$57.20
|
| Rate for Payer: United Healthcare Medicare |
$16.00
|
| Rate for Payer: Veterans Affairs TRICARE |
$15.84
|
|
|
F002-IgE Milk (Cow) LC
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2269479
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$54.00 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Aetna of AZ Commercial |
$54.00
|
| Rate for Payer: Cash Price |
$48.00
|
|
|
F002-IgE Milk (Cow) LC
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2269479
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.57 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Aetna of AZ Commercial |
$54.00
|
| Rate for Payer: Arizona Complete Health Allwell |
$9.60
|
| Rate for Payer: Banner UC Health Medicare |
$9.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$40.80
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$9.60
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$9.60
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna of AZ Commercial |
$39.00
|
| Rate for Payer: Devoted Health Medicare |
$10.80
|
| Rate for Payer: Humana of AZ Medicare |
$9.60
|
| Rate for Payer: Seven Corners Travel Insurance |
$7.57
|
| Rate for Payer: Southwest Service Administrators UFCW |
$40.80
|
| Rate for Payer: TriWest Medicare |
$9.60
|
| Rate for Payer: United Healthcare Commercial |
$34.32
|
| Rate for Payer: United Healthcare Medicare |
$9.60
|
| Rate for Payer: Veterans Affairs TRICARE |
$9.50
|
|
|
F004-IgE Wheat LC
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2269464
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.57 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna of AZ Commercial |
$43.20
|
| Rate for Payer: Arizona Complete Health Allwell |
$7.68
|
| Rate for Payer: Banner UC Health Medicare |
$7.68
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$32.64
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$7.68
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$7.68
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna of AZ Commercial |
$31.20
|
| Rate for Payer: Devoted Health Medicare |
$8.64
|
| Rate for Payer: Humana of AZ Medicare |
$7.68
|
| Rate for Payer: Seven Corners Travel Insurance |
$7.57
|
| Rate for Payer: Southwest Service Administrators UFCW |
$32.64
|
| Rate for Payer: TriWest Medicare |
$7.68
|
| Rate for Payer: United Healthcare Commercial |
$27.46
|
| Rate for Payer: United Healthcare Medicare |
$7.68
|
| Rate for Payer: Veterans Affairs TRICARE |
$7.60
|
|
|
F004-IgE Wheat LC
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2269464
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$43.20 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna of AZ Commercial |
$43.20
|
| Rate for Payer: Cash Price |
$38.40
|
|
|
F044-IgE Strawberry LC
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2087586
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$52.20 |
| Max. Negotiated Rate |
$52.20 |
| Rate for Payer: Aetna of AZ Commercial |
$52.20
|
| Rate for Payer: Cash Price |
$46.40
|
|
|
F044-IgE Strawberry LC
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2087586
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.57 |
| Max. Negotiated Rate |
$52.20 |
| Rate for Payer: Aetna of AZ Commercial |
$52.20
|
| Rate for Payer: Arizona Complete Health Allwell |
$9.28
|
| Rate for Payer: Banner UC Health Medicare |
$9.28
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$39.44
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$9.28
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$9.28
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Cigna of AZ Commercial |
$37.70
|
| Rate for Payer: Devoted Health Medicare |
$10.44
|
| Rate for Payer: Humana of AZ Medicare |
$9.28
|
| Rate for Payer: Seven Corners Travel Insurance |
$7.57
|
| Rate for Payer: Southwest Service Administrators UFCW |
$39.44
|
| Rate for Payer: TriWest Medicare |
$9.28
|
| Rate for Payer: United Healthcare Commercial |
$33.18
|
| Rate for Payer: United Healthcare Medicare |
$9.28
|
| Rate for Payer: Veterans Affairs TRICARE |
$9.19
|
|
|
Face to Face Home Health Nursing Visit by RHC
|
Facility
|
OP
|
$264.00
|
|
|
Service Code
|
HCPCS G0490
|
| Hospital Charge Code |
27342349
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$41.82 |
| Max. Negotiated Rate |
$237.60 |
| Rate for Payer: Aetna of AZ Commercial |
$237.60
|
| Rate for Payer: Arizona Complete Health Allwell |
$42.24
|
| Rate for Payer: Banner UC Health Medicare |
$42.24
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$179.52
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$42.24
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$42.24
|
| Rate for Payer: Cash Price |
$211.20
|
| Rate for Payer: Cigna of AZ Commercial |
$184.80
|
| Rate for Payer: Devoted Health Medicare |
$47.52
|
| Rate for Payer: Humana of AZ Medicare |
$42.24
|
| Rate for Payer: Southwest Service Administrators UFCW |
$179.52
|
| Rate for Payer: TriWest Medicare |
$42.24
|
| Rate for Payer: United Healthcare Commercial |
$151.01
|
| Rate for Payer: United Healthcare Medicare |
$42.24
|
| Rate for Payer: Veterans Affairs TRICARE |
$41.82
|
|
|
Face to Face Home Health Nursing Visit by RHC
|
Facility
|
IP
|
$264.00
|
|
|
Service Code
|
HCPCS G0490
|
| Hospital Charge Code |
27342349
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$237.60 |
| Max. Negotiated Rate |
$237.60 |
| Rate for Payer: Aetna of AZ Commercial |
$237.60
|
| Rate for Payer: Cash Price |
$211.20
|
|
|
Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures
|
Facility
|
IP
|
$17,975.48
|
|
|
Service Code
|
APR-DRG 0923
|
| Hospital Charge Code |
APRDRG0922
|
| Min. Negotiated Rate |
$17,975.48 |
| Max. Negotiated Rate |
$17,975.48 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$17,975.48
|
| Rate for Payer: Mercy Care Medicaid |
$17,975.48
|
| Rate for Payer: NaphCare Correctional Healthcare |
$17,975.48
|
|
|
Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures
|
Facility
|
IP
|
$11,444.74
|
|
|
Service Code
|
APR-DRG 0922
|
| Hospital Charge Code |
APRDRG0924
|
| Min. Negotiated Rate |
$11,444.74 |
| Max. Negotiated Rate |
$11,444.74 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$11,444.74
|
| Rate for Payer: Mercy Care Medicaid |
$11,444.74
|
| Rate for Payer: NaphCare Correctional Healthcare |
$11,444.74
|
|
|
Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures
|
Facility
|
IP
|
$17,975.48
|
|
|
Service Code
|
APR-DRG 0923
|
| Hospital Charge Code |
APRDRG0923
|
| Min. Negotiated Rate |
$17,975.48 |
| Max. Negotiated Rate |
$17,975.48 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$17,975.48
|
| Rate for Payer: Mercy Care Medicaid |
$17,975.48
|
| Rate for Payer: NaphCare Correctional Healthcare |
$17,975.48
|
|
|
Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures
|
Facility
|
IP
|
$11,444.74
|
|
|
Service Code
|
APR-DRG 0922
|
| Hospital Charge Code |
APRDRG0922
|
| Min. Negotiated Rate |
$11,444.74 |
| Max. Negotiated Rate |
$11,444.74 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$11,444.74
|
| Rate for Payer: Mercy Care Medicaid |
$11,444.74
|
| Rate for Payer: NaphCare Correctional Healthcare |
$11,444.74
|
|
|
Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures
|
Facility
|
IP
|
$32,267.91
|
|
|
Service Code
|
APR-DRG 0924
|
| Hospital Charge Code |
APRDRG0923
|
| Min. Negotiated Rate |
$32,267.91 |
| Max. Negotiated Rate |
$32,267.91 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$32,267.91
|
| Rate for Payer: Mercy Care Medicaid |
$32,267.91
|
| Rate for Payer: NaphCare Correctional Healthcare |
$32,267.91
|
|
|
Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures
|
Facility
|
IP
|
$11,444.74
|
|
|
Service Code
|
APR-DRG 0922
|
| Hospital Charge Code |
APRDRG0923
|
| Min. Negotiated Rate |
$11,444.74 |
| Max. Negotiated Rate |
$11,444.74 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$11,444.74
|
| Rate for Payer: Mercy Care Medicaid |
$11,444.74
|
| Rate for Payer: NaphCare Correctional Healthcare |
$11,444.74
|
|
|
Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures
|
Facility
|
IP
|
$17,975.48
|
|
|
Service Code
|
APR-DRG 0923
|
| Hospital Charge Code |
APRDRG0924
|
| Min. Negotiated Rate |
$17,975.48 |
| Max. Negotiated Rate |
$17,975.48 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$17,975.48
|
| Rate for Payer: Mercy Care Medicaid |
$17,975.48
|
| Rate for Payer: NaphCare Correctional Healthcare |
$17,975.48
|
|
