|
Female Reproductive System Reconstructive Procedures
|
Facility
|
IP
|
$5,050.08
|
|
|
Service Code
|
APR-DRG 5141
|
| Hospital Charge Code |
APRDRG5142
|
| Min. Negotiated Rate |
$5,050.08 |
| Max. Negotiated Rate |
$5,050.08 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,050.08
|
| Rate for Payer: Mercy Care Medicaid |
$5,050.08
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,050.08
|
|
|
Female Reproductive System Reconstructive Procedures
|
Facility
|
IP
|
$14,027.30
|
|
|
Service Code
|
APR-DRG 5143
|
| Hospital Charge Code |
APRDRG5143
|
| Min. Negotiated Rate |
$14,027.30 |
| Max. Negotiated Rate |
$14,027.30 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$14,027.30
|
| Rate for Payer: Mercy Care Medicaid |
$14,027.30
|
| Rate for Payer: NaphCare Correctional Healthcare |
$14,027.30
|
|
|
Female Reproductive System Reconstructive Procedures
|
Facility
|
IP
|
$7,769.41
|
|
|
Service Code
|
APR-DRG 5142
|
| Hospital Charge Code |
APRDRG5143
|
| Min. Negotiated Rate |
$7,769.41 |
| Max. Negotiated Rate |
$7,769.41 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$7,769.41
|
| Rate for Payer: Mercy Care Medicaid |
$7,769.41
|
| Rate for Payer: NaphCare Correctional Healthcare |
$7,769.41
|
|
|
Female Reproductive System Reconstructive Procedures
|
Facility
|
IP
|
$5,050.08
|
|
|
Service Code
|
APR-DRG 5141
|
| Hospital Charge Code |
APRDRG5144
|
| Min. Negotiated Rate |
$5,050.08 |
| Max. Negotiated Rate |
$5,050.08 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,050.08
|
| Rate for Payer: Mercy Care Medicaid |
$5,050.08
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,050.08
|
|
|
Female Reproductive System Reconstructive Procedures
|
Facility
|
IP
|
$5,050.08
|
|
|
Service Code
|
APR-DRG 5141
|
| Hospital Charge Code |
APRDRG5143
|
| Min. Negotiated Rate |
$5,050.08 |
| Max. Negotiated Rate |
$5,050.08 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,050.08
|
| Rate for Payer: Mercy Care Medicaid |
$5,050.08
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,050.08
|
|
|
Female Reproductive System Reconstructive Procedures
|
Facility
|
IP
|
$25,511.32
|
|
|
Service Code
|
APR-DRG 5144
|
| Hospital Charge Code |
APRDRG5144
|
| Min. Negotiated Rate |
$25,511.32 |
| Max. Negotiated Rate |
$25,511.32 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$25,511.32
|
| Rate for Payer: Mercy Care Medicaid |
$25,511.32
|
| Rate for Payer: NaphCare Correctional Healthcare |
$25,511.32
|
|
|
Female Reproductive System Reconstructive Procedures
|
Facility
|
IP
|
$14,027.30
|
|
|
Service Code
|
APR-DRG 5143
|
| Hospital Charge Code |
APRDRG5144
|
| Min. Negotiated Rate |
$14,027.30 |
| Max. Negotiated Rate |
$14,027.30 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$14,027.30
|
| Rate for Payer: Mercy Care Medicaid |
$14,027.30
|
| Rate for Payer: NaphCare Correctional Healthcare |
$14,027.30
|
|
|
Female Reproductive System Reconstructive Procedures
|
Facility
|
IP
|
$25,511.32
|
|
|
Service Code
|
APR-DRG 5144
|
| Hospital Charge Code |
APRDRG5141
|
| Min. Negotiated Rate |
$25,511.32 |
| Max. Negotiated Rate |
$25,511.32 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$25,511.32
|
| Rate for Payer: Mercy Care Medicaid |
$25,511.32
|
| Rate for Payer: NaphCare Correctional Healthcare |
$25,511.32
|
|
|
Female Reproductive System Reconstructive Procedures
|
Facility
|
IP
|
$14,027.30
|
|
|
Service Code
|
APR-DRG 5143
|
| Hospital Charge Code |
APRDRG5141
|
| Min. Negotiated Rate |
$14,027.30 |
| Max. Negotiated Rate |
$14,027.30 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$14,027.30
|
| Rate for Payer: Mercy Care Medicaid |
$14,027.30
|
| Rate for Payer: NaphCare Correctional Healthcare |
$14,027.30
|
|
|
Female Reproductive System Reconstructive Procedures
|
Facility
|
IP
|
$7,769.41
|
|
|
Service Code
|
APR-DRG 5142
|
| Hospital Charge Code |
APRDRG5141
|
| Min. Negotiated Rate |
$7,769.41 |
| Max. Negotiated Rate |
$7,769.41 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$7,769.41
|
| Rate for Payer: Mercy Care Medicaid |
$7,769.41
|
| Rate for Payer: NaphCare Correctional Healthcare |
$7,769.41
|
|
|
Female Reproductive System Reconstructive Procedures
|
Facility
|
IP
|
$7,769.41
|
|
|
Service Code
|
APR-DRG 5142
|
| Hospital Charge Code |
APRDRG5142
|
| Min. Negotiated Rate |
$7,769.41 |
| Max. Negotiated Rate |
$7,769.41 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$7,769.41
|
| Rate for Payer: Mercy Care Medicaid |
$7,769.41
|
| Rate for Payer: NaphCare Correctional Healthcare |
$7,769.41
|
|
|
Female Reproductive System Reconstructive Procedures
|
Facility
|
IP
|
$25,511.32
|
|
|
Service Code
|
APR-DRG 5144
|
| Hospital Charge Code |
APRDRG5142
|
| Min. Negotiated Rate |
$25,511.32 |
| Max. Negotiated Rate |
$25,511.32 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$25,511.32
|
| Rate for Payer: Mercy Care Medicaid |
$25,511.32
|
| Rate for Payer: NaphCare Correctional Healthcare |
$25,511.32
|
|
|
Female Reproductive System Reconstructive Procedures
|
Facility
|
IP
|
$7,769.41
|
|
|
Service Code
|
APR-DRG 5142
|
| Hospital Charge Code |
APRDRG5144
|
| Min. Negotiated Rate |
$7,769.41 |
| Max. Negotiated Rate |
$7,769.41 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$7,769.41
|
| Rate for Payer: Mercy Care Medicaid |
$7,769.41
|
| Rate for Payer: NaphCare Correctional Healthcare |
$7,769.41
|
|
|
Female Reproductive System Reconstructive Procedures
|
Facility
|
IP
|
$14,027.30
|
|
|
Service Code
|
APR-DRG 5143
|
| Hospital Charge Code |
APRDRG5142
|
| Min. Negotiated Rate |
$14,027.30 |
| Max. Negotiated Rate |
$14,027.30 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$14,027.30
|
| Rate for Payer: Mercy Care Medicaid |
$14,027.30
|
| Rate for Payer: NaphCare Correctional Healthcare |
$14,027.30
|
|
|
Female Reproductive System Reconstructive Procedures
|
Facility
|
IP
|
$25,511.32
|
|
|
Service Code
|
APR-DRG 5144
|
| Hospital Charge Code |
APRDRG5143
|
| Min. Negotiated Rate |
$25,511.32 |
| Max. Negotiated Rate |
$25,511.32 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$25,511.32
|
| Rate for Payer: Mercy Care Medicaid |
$25,511.32
|
| Rate for Payer: NaphCare Correctional Healthcare |
$25,511.32
|
|
|
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
|
Facility
|
IP
|
$17,934.17
|
|
|
Service Code
|
MSDRG 748
|
| Min. Negotiated Rate |
$17,934.17 |
| Max. Negotiated Rate |
$17,934.17 |
| Rate for Payer: Seven Corners Travel Insurance |
$17,934.17
|
|
|
fentaNYL 100 mcg/2 mL Inj Sol [CQCH]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
105922514
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna of AZ Commercial |
$0.56
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.10
|
| Rate for Payer: Banner UC Health Medicare |
$0.10
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.42
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.10
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of AZ Commercial |
$0.40
|
| Rate for Payer: Devoted Health Medicare |
$0.11
|
| Rate for Payer: Humana of AZ Medicare |
$0.10
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.42
|
| Rate for Payer: TriWest Medicare |
$0.10
|
| Rate for Payer: United Healthcare Commercial |
$0.35
|
| Rate for Payer: United Healthcare Medicare |
$0.10
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.10
|
|
|
fentaNYL 100 mcg/2 mL Inj Sol [CQCH]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
105922514
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna of AZ Commercial |
$0.56
|
| Rate for Payer: Cash Price |
$0.50
|
|
|
fentaNYL 12 mcg/hr TD Patch [CQCH]
|
Facility
|
OP
|
$12.11
|
|
|
Service Code
|
NDC 378911998
|
| Hospital Charge Code |
105922174
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$1.92 |
| Max. Negotiated Rate |
$10.90 |
| Rate for Payer: Aetna of AZ Commercial |
$10.90
|
| Rate for Payer: Arizona Complete Health Allwell |
$1.94
|
| Rate for Payer: Banner UC Health Medicare |
$1.94
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$8.23
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$1.94
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$1.94
|
| Rate for Payer: Cash Price |
$9.69
|
| Rate for Payer: Cigna of AZ Commercial |
$7.87
|
| Rate for Payer: Devoted Health Medicare |
$2.18
|
| Rate for Payer: Humana of AZ Medicare |
$1.94
|
| Rate for Payer: Southwest Service Administrators UFCW |
$8.23
|
| Rate for Payer: TriWest Medicare |
$1.94
|
| Rate for Payer: United Healthcare Commercial |
$6.93
|
| Rate for Payer: United Healthcare Medicare |
$1.94
|
| Rate for Payer: Veterans Affairs TRICARE |
$1.92
|
|
|
fentaNYL 12 mcg/hr TD Patch [CQCH]
|
Facility
|
IP
|
$12.11
|
|
|
Service Code
|
NDC 378911998
|
| Hospital Charge Code |
105922174
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$10.90 |
| Max. Negotiated Rate |
$10.90 |
| Rate for Payer: Aetna of AZ Commercial |
$10.90
|
| Rate for Payer: Cash Price |
$9.69
|
|
|
fentaNYL 25 mcg/hr TD Patch [CQCH]
|
Facility
|
OP
|
$1.65
|
|
|
Service Code
|
NDC 47781042447
|
| Hospital Charge Code |
105922300
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.49 |
| Rate for Payer: Aetna of AZ Commercial |
$1.49
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.26
|
| Rate for Payer: Banner UC Health Medicare |
$0.26
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$1.12
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.26
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.26
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of AZ Commercial |
$1.07
|
| Rate for Payer: Devoted Health Medicare |
$0.30
|
| Rate for Payer: Humana of AZ Medicare |
$0.26
|
| Rate for Payer: Southwest Service Administrators UFCW |
$1.12
|
| Rate for Payer: TriWest Medicare |
$0.26
|
| Rate for Payer: United Healthcare Commercial |
$0.94
|
| Rate for Payer: United Healthcare Medicare |
$0.26
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.26
|
|
|
fentaNYL 25 mcg/hr TD Patch [CQCH]
|
Facility
|
IP
|
$1.65
|
|
|
Service Code
|
NDC 47781042447
|
| Hospital Charge Code |
105922300
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$1.49 |
| Rate for Payer: Aetna of AZ Commercial |
$1.49
|
| Rate for Payer: Cash Price |
$1.32
|
|
|
fentaNYL 50 mcg/hr TD patch [CQCH]
|
Facility
|
OP
|
$12.58
|
|
|
Service Code
|
NDC 378912298
|
| Hospital Charge Code |
105922453
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$11.32 |
| Rate for Payer: Aetna of AZ Commercial |
$11.32
|
| Rate for Payer: Arizona Complete Health Allwell |
$2.01
|
| Rate for Payer: Banner UC Health Medicare |
$2.01
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$8.55
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$2.01
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$2.01
|
| Rate for Payer: Cash Price |
$10.07
|
| Rate for Payer: Cigna of AZ Commercial |
$8.18
|
| Rate for Payer: Devoted Health Medicare |
$2.26
|
| Rate for Payer: Humana of AZ Medicare |
$2.01
|
| Rate for Payer: Southwest Service Administrators UFCW |
$8.55
|
| Rate for Payer: TriWest Medicare |
$2.01
|
| Rate for Payer: United Healthcare Commercial |
$7.20
|
| Rate for Payer: United Healthcare Medicare |
$2.01
|
| Rate for Payer: Veterans Affairs TRICARE |
$1.99
|
|
|
fentaNYL 50 mcg/hr TD patch [CQCH]
|
Facility
|
IP
|
$12.58
|
|
|
Service Code
|
NDC 378912298
|
| Hospital Charge Code |
105922453
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$11.32 |
| Max. Negotiated Rate |
$11.32 |
| Rate for Payer: Aetna of AZ Commercial |
$11.32
|
| Rate for Payer: Cash Price |
$10.07
|
|
|
FERNOTRAC TRACTION SPLINT ADULT
|
Facility
|
OP
|
$1,546.00
|
|
| Hospital Charge Code |
24335304
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$244.89 |
| Max. Negotiated Rate |
$1,391.40 |
| Rate for Payer: Aetna of AZ Commercial |
$1,391.40
|
| Rate for Payer: Arizona Complete Health Allwell |
$247.36
|
| Rate for Payer: Banner UC Health Medicare |
$247.36
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$1,051.28
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$247.36
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$247.36
|
| Rate for Payer: Cash Price |
$1,236.80
|
| Rate for Payer: Cigna of AZ Commercial |
$1,082.20
|
| Rate for Payer: Devoted Health Medicare |
$278.28
|
| Rate for Payer: Humana of AZ Medicare |
$247.36
|
| Rate for Payer: Southwest Service Administrators UFCW |
$1,051.28
|
| Rate for Payer: TriWest Medicare |
$247.36
|
| Rate for Payer: United Healthcare Commercial |
$884.31
|
| Rate for Payer: United Healthcare Medicare |
$247.36
|
| Rate for Payer: Veterans Affairs TRICARE |
$244.89
|
|
