|
famotidine 20 mg Tab [CQCH]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 62332000131
|
| Hospital Charge Code |
105921837
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of AZ Commercial |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
|
|
famotidine 20 mg Tab [CQCH]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 62332000131
|
| Hospital Charge Code |
105921837
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of AZ Commercial |
$0.17
|
| 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 |
$0.13
|
| 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 |
$0.15
|
| Rate for Payer: Cigna of AZ Commercial |
$0.12
|
| Rate for Payer: Devoted Health Medicare |
$0.03
|
| Rate for Payer: Humana of AZ Medicare |
$0.03
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.13
|
| Rate for Payer: TriWest Medicare |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.11
|
| Rate for Payer: United Healthcare Medicare |
$0.03
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.03
|
|
|
FASCIECTOMY, PLANTAR FASCIA; PARTIAL (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$5,062.66
|
|
|
Service Code
|
CPT 28060
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$152.37 |
| Max. Negotiated Rate |
$5,062.66 |
| Rate for Payer: Banner UC Health Medicare |
$1,062.88
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$152.37
|
| Rate for Payer: Mercy Care Medicaid |
$152.37
|
| Rate for Payer: NaphCare Correctional Healthcare |
$1,062.88
|
| Rate for Payer: Seven Corners Travel Insurance |
$5,062.66
|
| Rate for Payer: United Healthcare Commercial |
$4,169.00
|
|
|
FASTPITCH 2.7MM LONG SCREW PLATE 12 AND 14MM
|
Facility
|
OP
|
$6,415.00
|
|
| Hospital Charge Code |
27431790
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,016.14 |
| Max. Negotiated Rate |
$5,773.50 |
| Rate for Payer: Aetna of AZ Commercial |
$5,773.50
|
| Rate for Payer: Arizona Complete Health Allwell |
$1,026.40
|
| Rate for Payer: Banner UC Health Medicare |
$1,026.40
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$4,362.20
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$1,026.40
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$1,026.40
|
| Rate for Payer: Cash Price |
$5,132.00
|
| Rate for Payer: Cigna of AZ Commercial |
$4,490.50
|
| Rate for Payer: Devoted Health Medicare |
$1,154.70
|
| Rate for Payer: Humana of AZ Medicare |
$1,026.40
|
| Rate for Payer: Southwest Service Administrators UFCW |
$4,362.20
|
| Rate for Payer: TriWest Medicare |
$1,026.40
|
| Rate for Payer: United Healthcare Commercial |
$3,669.38
|
| Rate for Payer: United Healthcare Medicare |
$1,026.40
|
| Rate for Payer: Veterans Affairs TRICARE |
$1,016.14
|
|
|
FASTPITCH 2.7MM LONG SCREW PLATE 12 AND 14MM
|
Facility
|
IP
|
$6,415.00
|
|
| Hospital Charge Code |
27431790
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5,773.50 |
| Max. Negotiated Rate |
$5,773.50 |
| Rate for Payer: Aetna of AZ Commercial |
$5,773.50
|
| Rate for Payer: Cash Price |
$5,132.00
|
|
|
FASTPITCY 2.7MM LONG SCREW PLATE
|
Facility
|
OP
|
$6,736.00
|
|
| Hospital Charge Code |
27431789
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,066.98 |
| Max. Negotiated Rate |
$6,062.40 |
| Rate for Payer: Aetna of AZ Commercial |
$6,062.40
|
| Rate for Payer: Arizona Complete Health Allwell |
$1,077.76
|
| Rate for Payer: Banner UC Health Medicare |
$1,077.76
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$4,580.48
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$1,077.76
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$1,077.76
|
| Rate for Payer: Cash Price |
$5,388.80
|
| Rate for Payer: Cigna of AZ Commercial |
$4,715.20
|
| Rate for Payer: Devoted Health Medicare |
$1,212.48
|
| Rate for Payer: Humana of AZ Medicare |
$1,077.76
|
| Rate for Payer: Southwest Service Administrators UFCW |
$4,580.48
|
| Rate for Payer: TriWest Medicare |
$1,077.76
|
| Rate for Payer: United Healthcare Commercial |
$3,852.99
|
| Rate for Payer: United Healthcare Medicare |
$1,077.76
|
| Rate for Payer: Veterans Affairs TRICARE |
$1,066.98
|
|
|
FASTPITCY 2.7MM LONG SCREW PLATE
|
Facility
|
IP
|
$6,736.00
|
|
| Hospital Charge Code |
27431789
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6,062.40 |
| Max. Negotiated Rate |
$6,062.40 |
| Rate for Payer: Aetna of AZ Commercial |
$6,062.40
|
| Rate for Payer: Cash Price |
$5,388.80
|
|
|
fat emulsion 20%, IV 250 mL [CQCH]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 338051909
|
| Hospital Charge Code |
109336288
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of AZ Commercial |
$0.14
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.02
|
| Rate for Payer: Banner UC Health Medicare |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.10
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.02
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of AZ Commercial |
$0.10
|
| Rate for Payer: Devoted Health Medicare |
$0.03
|
| Rate for Payer: Humana of AZ Medicare |
$0.02
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.10
|
| Rate for Payer: TriWest Medicare |
$0.02
|
| Rate for Payer: United Healthcare Commercial |
$0.09
|
| Rate for Payer: United Healthcare Medicare |
$0.02
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.02
|
|
|
fat emulsion 20%, IV 250 mL [CQCH]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 338051909
|
| Hospital Charge Code |
109336288
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of AZ Commercial |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
|
|
FATTY ACIDS, NONESTERIFIED
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT 82725
|
| Hospital Charge Code |
23143916
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna of AZ Commercial |
$45.00
|
| Rate for Payer: Arizona Complete Health Allwell |
$8.00
|
| Rate for Payer: Banner UC Health Medicare |
$8.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$34.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$8.00
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$8.00
|
| Rate for Payer: Cash Price |
$40.00
|
| Rate for Payer: Cash Price |
$40.00
|
| Rate for Payer: Cigna of AZ Commercial |
$32.50
|
| Rate for Payer: Devoted Health Medicare |
$9.00
|
| Rate for Payer: Humana of AZ Medicare |
$8.00
|
| Rate for Payer: Seven Corners Travel Insurance |
$27.22
|
| Rate for Payer: Southwest Service Administrators UFCW |
$34.00
|
| Rate for Payer: TriWest Medicare |
$8.00
|
| Rate for Payer: United Healthcare Commercial |
$28.60
|
| Rate for Payer: United Healthcare Medicare |
$8.00
|
| Rate for Payer: Veterans Affairs TRICARE |
$7.92
|
|
|
FATTY ACIDS, NONESTERIFIED
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
CPT 82725
|
| Hospital Charge Code |
23143916
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna of AZ Commercial |
$45.00
|
| Rate for Payer: Cash Price |
$40.00
|
|
|
FDP, Plasma LC
|
Facility
|
IP
|
$142.00
|
|
|
Service Code
|
CPT 85362
|
| Hospital Charge Code |
2087589
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$127.80 |
| Max. Negotiated Rate |
$127.80 |
| Rate for Payer: Aetna of AZ Commercial |
$127.80
|
| Rate for Payer: Cash Price |
$113.60
|
|
|
FDP, Plasma LC
|
Facility
|
OP
|
$142.00
|
|
|
Service Code
|
CPT 85362
|
| Hospital Charge Code |
2087589
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$9.99 |
| Max. Negotiated Rate |
$127.80 |
| Rate for Payer: Aetna of AZ Commercial |
$127.80
|
| Rate for Payer: Arizona Complete Health Allwell |
$22.72
|
| Rate for Payer: Banner UC Health Medicare |
$22.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$96.56
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$22.72
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$22.72
|
| Rate for Payer: Cash Price |
$113.60
|
| Rate for Payer: Cash Price |
$113.60
|
| Rate for Payer: Cigna of AZ Commercial |
$92.30
|
| Rate for Payer: Devoted Health Medicare |
$25.56
|
| Rate for Payer: Humana of AZ Medicare |
$22.72
|
| Rate for Payer: Seven Corners Travel Insurance |
$9.99
|
| Rate for Payer: Southwest Service Administrators UFCW |
$96.56
|
| Rate for Payer: TriWest Medicare |
$22.72
|
| Rate for Payer: United Healthcare Commercial |
$81.22
|
| Rate for Payer: United Healthcare Medicare |
$22.72
|
| Rate for Payer: Veterans Affairs TRICARE |
$22.49
|
|
|
Fecal Fat, Qualitative LC
|
Facility
|
IP
|
$117.00
|
|
|
Service Code
|
CPT 82705
|
| Hospital Charge Code |
2087590
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$105.30 |
| Max. Negotiated Rate |
$105.30 |
| Rate for Payer: Aetna of AZ Commercial |
$105.30
|
| Rate for Payer: Cash Price |
$93.60
|
|
|
Fecal Fat, Qualitative LC
|
Facility
|
OP
|
$117.00
|
|
|
Service Code
|
CPT 82705
|
| Hospital Charge Code |
2087590
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.39 |
| Max. Negotiated Rate |
$105.30 |
| Rate for Payer: Aetna of AZ Commercial |
$105.30
|
| Rate for Payer: Arizona Complete Health Allwell |
$18.72
|
| Rate for Payer: Banner UC Health Medicare |
$18.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$79.56
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$18.72
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$18.72
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cigna of AZ Commercial |
$76.05
|
| Rate for Payer: Devoted Health Medicare |
$21.06
|
| Rate for Payer: Humana of AZ Medicare |
$18.72
|
| Rate for Payer: Seven Corners Travel Insurance |
$7.39
|
| Rate for Payer: Southwest Service Administrators UFCW |
$79.56
|
| Rate for Payer: TriWest Medicare |
$18.72
|
| Rate for Payer: United Healthcare Commercial |
$66.92
|
| Rate for Payer: United Healthcare Medicare |
$18.72
|
| Rate for Payer: Veterans Affairs TRICARE |
$18.53
|
|
|
felodipine 5 mg ER Tab [CQCH]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 23155004901
|
| Hospital Charge Code |
105922038
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of AZ Commercial |
$0.10
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.02
|
| Rate for Payer: Banner UC Health Medicare |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.07
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.02
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of AZ Commercial |
$0.07
|
| Rate for Payer: Devoted Health Medicare |
$0.02
|
| Rate for Payer: Humana of AZ Medicare |
$0.02
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.07
|
| Rate for Payer: TriWest Medicare |
$0.02
|
| Rate for Payer: United Healthcare Commercial |
$0.06
|
| Rate for Payer: United Healthcare Medicare |
$0.02
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.02
|
|
|
felodipine 5 mg ER Tab [CQCH]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 23155004901
|
| Hospital Charge Code |
105922038
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of AZ Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
|
|
Female Reproductive System Infections
|
Facility
|
IP
|
$12,709.37
|
|
|
Service Code
|
APR-DRG 5314
|
| Hospital Charge Code |
APRDRG5313
|
| Min. Negotiated Rate |
$12,709.37 |
| Max. Negotiated Rate |
$12,709.37 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$12,709.37
|
| Rate for Payer: Mercy Care Medicaid |
$12,709.37
|
| Rate for Payer: NaphCare Correctional Healthcare |
$12,709.37
|
|
|
Female Reproductive System Infections
|
Facility
|
IP
|
$6,993.66
|
|
|
Service Code
|
APR-DRG 5313
|
| Hospital Charge Code |
APRDRG5311
|
| 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
|
|
|
Female Reproductive System Infections
|
Facility
|
IP
|
$6,993.66
|
|
|
Service Code
|
APR-DRG 5313
|
| Hospital Charge Code |
APRDRG5314
|
| 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
|
|
|
Female Reproductive System Infections
|
Facility
|
IP
|
$12,709.37
|
|
|
Service Code
|
APR-DRG 5314
|
| Hospital Charge Code |
APRDRG5314
|
| Min. Negotiated Rate |
$12,709.37 |
| Max. Negotiated Rate |
$12,709.37 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$12,709.37
|
| Rate for Payer: Mercy Care Medicaid |
$12,709.37
|
| Rate for Payer: NaphCare Correctional Healthcare |
$12,709.37
|
|
|
Female Reproductive System Infections
|
Facility
|
IP
|
$6,993.66
|
|
|
Service Code
|
APR-DRG 5313
|
| Hospital Charge Code |
APRDRG5312
|
| 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
|
|
|
Female Reproductive System Infections
|
Facility
|
IP
|
$3,251.69
|
|
|
Service Code
|
APR-DRG 5311
|
| Hospital Charge Code |
APRDRG5313
|
| Min. Negotiated Rate |
$3,251.69 |
| Max. Negotiated Rate |
$3,251.69 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,251.69
|
| Rate for Payer: Mercy Care Medicaid |
$3,251.69
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,251.69
|
|
|
Female Reproductive System Infections
|
Facility
|
IP
|
$3,251.69
|
|
|
Service Code
|
APR-DRG 5311
|
| Hospital Charge Code |
APRDRG5314
|
| Min. Negotiated Rate |
$3,251.69 |
| Max. Negotiated Rate |
$3,251.69 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,251.69
|
| Rate for Payer: Mercy Care Medicaid |
$3,251.69
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,251.69
|
|
|
Female Reproductive System Infections
|
Facility
|
IP
|
$3,251.69
|
|
|
Service Code
|
APR-DRG 5311
|
| Hospital Charge Code |
APRDRG5312
|
| Min. Negotiated Rate |
$3,251.69 |
| Max. Negotiated Rate |
$3,251.69 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,251.69
|
| Rate for Payer: Mercy Care Medicaid |
$3,251.69
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,251.69
|
|
