Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

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

$8,982.83

Service Code	APR-DRG 0921
Hospital Charge Code	APRDRG0922
Min. Negotiated Rate	$8,982.83
Max. Negotiated Rate	$8,982.83
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$8,982.83
Rate for Payer: Mercy Care Medicaid	$8,982.83
Rate for Payer: NaphCare Correctional Healthcare	$8,982.83

Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures

Facility

IP

$8,982.83

Service Code	APR-DRG 0921
Hospital Charge Code	APRDRG0923
Min. Negotiated Rate	$8,982.83
Max. Negotiated Rate	$8,982.83
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$8,982.83
Rate for Payer: Mercy Care Medicaid	$8,982.83
Rate for Payer: NaphCare Correctional Healthcare	$8,982.83

Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures

Facility

IP

$32,267.91

Service Code	APR-DRG 0924
Hospital Charge Code	APRDRG0922
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

$17,975.48

Service Code	APR-DRG 0923
Hospital Charge Code	APRDRG0921
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

$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

$11,444.74

Service Code	APR-DRG 0922
Hospital Charge Code	APRDRG0921
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

Factor II Activity LC

Facility

OP

$325.00

Service Code	CPT 85210
Hospital Charge Code	6738704
Hospital Revenue Code	305
Min. Negotiated Rate	$18.82
Max. Negotiated Rate	$292.50
Rate for Payer: Aetna of AZ Commercial	$292.50
Rate for Payer: Arizona Complete Health Allwell	$52.00
Rate for Payer: Banner UC Health Medicare	$52.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$221.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$52.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$52.00
Rate for Payer: Cash Price	$260.00
Rate for Payer: Cash Price	$260.00
Rate for Payer: Cigna of AZ Commercial	$211.25
Rate for Payer: Devoted Health Medicare	$58.50
Rate for Payer: Humana of AZ Medicare	$52.00
Rate for Payer: Seven Corners Travel Insurance	$18.82
Rate for Payer: Southwest Service Administrators UFCW	$221.00
Rate for Payer: TriWest Medicare	$52.00
Rate for Payer: United Healthcare Commercial	$185.90
Rate for Payer: United Healthcare Medicare	$52.00
Rate for Payer: Veterans Affairs TRICARE	$51.48

Factor II Activity LC

Facility

IP

$325.00

Service Code	CPT 85210
Hospital Charge Code	6738704
Hospital Revenue Code	305
Min. Negotiated Rate	$292.50
Max. Negotiated Rate	$292.50
Rate for Payer: Aetna of AZ Commercial	$292.50
Rate for Payer: Cash Price	$260.00

Factor II, DNA Analysis LC

Facility

IP

$776.00

Service Code	CPT 81240
Hospital Charge Code	2029232
Hospital Revenue Code	301
Min. Negotiated Rate	$698.40
Max. Negotiated Rate	$698.40
Rate for Payer: Aetna of AZ Commercial	$698.40
Rate for Payer: Cash Price	$620.80

Factor II, DNA Analysis LC

Facility

OP

$776.00

Service Code	CPT 81240
Hospital Charge Code	2029232
Hospital Revenue Code	301
Min. Negotiated Rate	$95.25
Max. Negotiated Rate	$698.40
Rate for Payer: Aetna of AZ Commercial	$698.40
Rate for Payer: Arizona Complete Health Allwell	$124.16
Rate for Payer: Banner UC Health Medicare	$124.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$527.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$124.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$124.16
Rate for Payer: Cash Price	$620.80
Rate for Payer: Cash Price	$620.80
Rate for Payer: Cigna of AZ Commercial	$504.40
Rate for Payer: Devoted Health Medicare	$139.68
Rate for Payer: Humana of AZ Medicare	$124.16
Rate for Payer: Seven Corners Travel Insurance	$95.25
Rate for Payer: Southwest Service Administrators UFCW	$527.68
Rate for Payer: TriWest Medicare	$124.16
Rate for Payer: United Healthcare Commercial	$443.87
Rate for Payer: United Healthcare Medicare	$124.16
Rate for Payer: Veterans Affairs TRICARE	$122.92

Factor VIII Activity LC

Facility

IP

$550.00

Service Code	CPT 85240
Hospital Charge Code	1906855
Hospital Revenue Code	305
Min. Negotiated Rate	$495.00
Max. Negotiated Rate	$495.00
Rate for Payer: Aetna of AZ Commercial	$495.00
Rate for Payer: Cash Price	$440.00

Factor VIII Activity LC

Facility

OP

$550.00

Service Code	CPT 85240
Hospital Charge Code	1906855
Hospital Revenue Code	305
Min. Negotiated Rate	$25.95
Max. Negotiated Rate	$495.00
Rate for Payer: Aetna of AZ Commercial	$495.00
Rate for Payer: Arizona Complete Health Allwell	$88.00
Rate for Payer: Banner UC Health Medicare	$88.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$374.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$88.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$88.00
Rate for Payer: Cash Price	$440.00
Rate for Payer: Cash Price	$440.00
Rate for Payer: Cigna of AZ Commercial	$357.50
Rate for Payer: Devoted Health Medicare	$99.00
Rate for Payer: Humana of AZ Medicare	$88.00
Rate for Payer: Seven Corners Travel Insurance	$25.95
Rate for Payer: Southwest Service Administrators UFCW	$374.00
Rate for Payer: TriWest Medicare	$88.00
Rate for Payer: United Healthcare Commercial	$314.60
Rate for Payer: United Healthcare Medicare	$88.00
Rate for Payer: Veterans Affairs TRICARE	$87.12

Factor V Leiden Mutation LC

Facility

OP

$866.00

Service Code	CPT 81241
Hospital Charge Code	1906847
Hospital Revenue Code	301
Min. Negotiated Rate	$106.39
Max. Negotiated Rate	$779.40
Rate for Payer: Aetna of AZ Commercial	$779.40
Rate for Payer: Arizona Complete Health Allwell	$138.56
Rate for Payer: Banner UC Health Medicare	$138.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$588.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$138.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$138.56
Rate for Payer: Cash Price	$692.80
Rate for Payer: Cash Price	$692.80
Rate for Payer: Cigna of AZ Commercial	$562.90
Rate for Payer: Devoted Health Medicare	$155.88
Rate for Payer: Humana of AZ Medicare	$138.56
Rate for Payer: Seven Corners Travel Insurance	$106.39
Rate for Payer: Southwest Service Administrators UFCW	$588.88
Rate for Payer: TriWest Medicare	$138.56
Rate for Payer: United Healthcare Commercial	$495.35
Rate for Payer: United Healthcare Medicare	$138.56
Rate for Payer: Veterans Affairs TRICARE	$137.17

Factor V Leiden Mutation LC

Facility

IP

$866.00

Service Code	CPT 81241
Hospital Charge Code	1906847
Hospital Revenue Code	301
Min. Negotiated Rate	$779.40
Max. Negotiated Rate	$779.40
Rate for Payer: Aetna of AZ Commercial	$779.40
Rate for Payer: Cash Price	$692.80

FALOPE-RING APPLICATION KIT

Facility

IP

$803.00

Hospital Charge Code	22354904
Hospital Revenue Code	270
Min. Negotiated Rate	$722.70
Max. Negotiated Rate	$722.70
Rate for Payer: Aetna of AZ Commercial	$722.70
Rate for Payer: Cash Price	$642.40

FALOPE-RING APPLICATION KIT

Facility

OP

$803.00

Hospital Charge Code	22354904
Hospital Revenue Code	270
Min. Negotiated Rate	$127.20
Max. Negotiated Rate	$722.70
Rate for Payer: Aetna of AZ Commercial	$722.70
Rate for Payer: Arizona Complete Health Allwell	$128.48
Rate for Payer: Banner UC Health Medicare	$128.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$546.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$128.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$128.48
Rate for Payer: Cash Price	$642.40
Rate for Payer: Cigna of AZ Commercial	$562.10
Rate for Payer: Devoted Health Medicare	$144.54
Rate for Payer: Humana of AZ Medicare	$128.48
Rate for Payer: Southwest Service Administrators UFCW	$546.04
Rate for Payer: TriWest Medicare	$128.48
Rate for Payer: United Healthcare Commercial	$459.32
Rate for Payer: United Healthcare Medicare	$128.48
Rate for Payer: Veterans Affairs TRICARE	$127.20

FALOPE-RING APPLICATION KIT w/TROCAR

Facility

OP

$843.00

Service Code	CPT 58671
Hospital Charge Code	22354903
Hospital Revenue Code	270
Min. Negotiated Rate	$133.53
Max. Negotiated Rate	$9,354.07
Rate for Payer: Aetna of AZ Commercial	$758.70
Rate for Payer: Arizona Complete Health Allwell	$134.88
Rate for Payer: Banner UC Health Medicare	$134.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$573.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$134.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$134.88
Rate for Payer: Cash Price	$674.40
Rate for Payer: Cash Price	$674.40
Rate for Payer: Cigna of AZ Commercial	$590.10
Rate for Payer: Devoted Health Medicare	$151.74
Rate for Payer: Humana of AZ Medicare	$134.88
Rate for Payer: Seven Corners Travel Insurance	$9,354.07
Rate for Payer: Southwest Service Administrators UFCW	$573.24
Rate for Payer: TriWest Medicare	$134.88
Rate for Payer: United Healthcare Commercial	$482.20
Rate for Payer: United Healthcare Medicare	$134.88
Rate for Payer: Veterans Affairs TRICARE	$133.53

FALOPE-RING APPLICATION KIT w/TROCAR

Facility

IP

$843.00

Service Code	CPT 58671
Hospital Charge Code	22354903
Hospital Revenue Code	270
Min. Negotiated Rate	$758.70
Max. Negotiated Rate	$758.70
Rate for Payer: Aetna of AZ Commercial	$758.70
Rate for Payer: Cash Price	$674.40

FALOPE-RING BAND

Facility

OP

$282.00

Hospital Charge Code	22355429
Hospital Revenue Code	270
Min. Negotiated Rate	$44.67
Max. Negotiated Rate	$253.80
Rate for Payer: Aetna of AZ Commercial	$253.80
Rate for Payer: Arizona Complete Health Allwell	$45.12
Rate for Payer: Banner UC Health Medicare	$45.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$191.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$45.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$45.12
Rate for Payer: Cash Price	$225.60
Rate for Payer: Cigna of AZ Commercial	$197.40
Rate for Payer: Devoted Health Medicare	$50.76
Rate for Payer: Humana of AZ Medicare	$45.12
Rate for Payer: Southwest Service Administrators UFCW	$191.76
Rate for Payer: TriWest Medicare	$45.12
Rate for Payer: United Healthcare Commercial	$161.30
Rate for Payer: United Healthcare Medicare	$45.12
Rate for Payer: Veterans Affairs TRICARE	$44.67

FALOPE-RING BAND

Facility

IP

$282.00

Hospital Charge Code	22355429
Hospital Revenue Code	270
Min. Negotiated Rate	$253.80
Max. Negotiated Rate	$253.80
Rate for Payer: Aetna of AZ Commercial	$253.80
Rate for Payer: Cash Price	$225.60

famotidine 10 mg/mL Inj Sol [CQCH]

Facility

OP

$0.40

Service Code	NDC 641602225
Hospital Charge Code	105921971
Hospital Revenue Code	251
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.36
Rate for Payer: Aetna of AZ Commercial	$0.36
Rate for Payer: Arizona Complete Health Allwell	$0.06
Rate for Payer: Banner UC Health Medicare	$0.06
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.27
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.06
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.06
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of AZ Commercial	$0.26
Rate for Payer: Devoted Health Medicare	$0.07
Rate for Payer: Humana of AZ Medicare	$0.06
Rate for Payer: Southwest Service Administrators UFCW	$0.27
Rate for Payer: TriWest Medicare	$0.06
Rate for Payer: United Healthcare Commercial	$0.23
Rate for Payer: United Healthcare Medicare	$0.06
Rate for Payer: Veterans Affairs TRICARE	$0.06

famotidine 10 mg/mL Inj Sol [CQCH]

Facility

IP

$0.40

Service Code	NDC 641602225
Hospital Charge Code	105921971
Hospital Revenue Code	251
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.36
Rate for Payer: Aetna of AZ Commercial	$0.36
Rate for Payer: Cash Price	$0.32

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