|
inclisiran 284 mg/1.5 mL Sol[CQCH]
|
Facility
|
OP
|
$2,254.28
|
|
|
Service Code
|
HCPCS J1306
|
| Hospital Charge Code |
242946825
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.18 |
| Max. Negotiated Rate |
$2,028.85 |
| Rate for Payer: Aetna of AZ Commercial |
$2,028.85
|
| Rate for Payer: Aetna of AZ Medicare |
$631.20
|
| Rate for Payer: AHCCCS Medicaid |
$19.18
|
| Rate for Payer: Allwell Medicaid |
$19.18
|
| Rate for Payer: Allwell Medicare |
$338.14
|
| Rate for Payer: Amerigroup Medicare |
$338.14
|
| Rate for Payer: APIPA Medicare/Medicaid |
$841.97
|
| Rate for Payer: AZCH Complete Medicaid |
$19.18
|
| Rate for Payer: AZCH Complete Medicare |
$338.14
|
| Rate for Payer: Banner UC Health Medicaid |
$19.18
|
| Rate for Payer: Banner UC Health Medicare |
$338.14
|
| Rate for Payer: Bisbee Police All Plans |
$586.11
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,532.91
|
| Rate for Payer: Cash Price |
$1,803.42
|
| Rate for Payer: Cash Price |
$1,803.42
|
| Rate for Payer: Cigna of AZ Commercial |
$1,465.28
|
| Rate for Payer: Copperpoint Commercial |
$557.93
|
| Rate for Payer: Health Net of AZ Commercial |
$1,352.57
|
| Rate for Payer: Health Net of AZ Medicare |
$631.20
|
| Rate for Payer: Humana of AZ Medicare |
$338.14
|
| Rate for Payer: Mercy Care Medicaid |
$19.18
|
| Rate for Payer: Self Pay Self Pay |
$1,803.42
|
| Rate for Payer: TriWest Medicare |
$338.14
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,314.25
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$405.77
|
|
|
indomethacin 25 mg Cap [CQCH]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 31722054201
|
| Hospital Charge Code |
105926578
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of AZ Commercial |
$0.17
|
| Rate for Payer: Bisbee Police All Plans |
$0.05
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Self Pay Self Pay |
$0.15
|
|
|
indomethacin 25 mg Cap [CQCH]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 31722054201
|
| Hospital Charge Code |
105926578
|
|
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: Aetna of AZ Medicare |
$0.05
|
| Rate for Payer: Allwell Medicare |
$0.03
|
| Rate for Payer: Amerigroup Medicare |
$0.03
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.07
|
| Rate for Payer: AZCH Complete Medicare |
$0.03
|
| Rate for Payer: Banner UC Health Medicare |
$0.03
|
| Rate for Payer: Bisbee Police All Plans |
$0.05
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.13
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of AZ Commercial |
$0.12
|
| Rate for Payer: Copperpoint Commercial |
$0.05
|
| Rate for Payer: Health Net of AZ Commercial |
$0.11
|
| Rate for Payer: Health Net of AZ Medicare |
$0.05
|
| Rate for Payer: Humana of AZ Medicare |
$0.03
|
| Rate for Payer: Self Pay Self Pay |
$0.15
|
| Rate for Payer: TriWest Medicare |
$0.03
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.11
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.03
|
|
|
INFANT NASAL PRNG 3MM TO 4MM
|
Facility
|
OP
|
$42.00
|
|
| Hospital Charge Code |
27704483
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Aetna of AZ Commercial |
$37.80
|
| Rate for Payer: Aetna of AZ Medicare |
$11.76
|
| Rate for Payer: Allwell Medicare |
$6.30
|
| Rate for Payer: Amerigroup Medicare |
$6.30
|
| Rate for Payer: APIPA Medicare/Medicaid |
$15.69
|
| Rate for Payer: AZCH Complete Medicare |
$6.30
|
| Rate for Payer: Banner UC Health Medicare |
$6.30
|
| Rate for Payer: Bisbee Police All Plans |
$10.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$28.56
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna of AZ Commercial |
$29.40
|
| Rate for Payer: Copperpoint Commercial |
$10.40
|
| Rate for Payer: Health Net of AZ Commercial |
$25.20
|
| Rate for Payer: Health Net of AZ Medicare |
$11.76
|
| Rate for Payer: Humana of AZ Medicare |
$6.30
|
| Rate for Payer: Self Pay Self Pay |
$33.60
|
| Rate for Payer: TriWest Medicare |
$6.30
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$24.49
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$7.56
|
|
|
INFANT NASAL PRNG 3MM TO 4MM
|
Facility
|
IP
|
$42.00
|
|
| Hospital Charge Code |
27704483
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.92 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Aetna of AZ Commercial |
$37.80
|
| Rate for Payer: Bisbee Police All Plans |
$10.92
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Self Pay Self Pay |
$33.60
|
|
|
INFANT NASAL PRNG 5MM TO 4MM
|
Facility
|
OP
|
$42.00
|
|
| Hospital Charge Code |
27704486
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Aetna of AZ Commercial |
$37.80
|
| Rate for Payer: Aetna of AZ Medicare |
$11.76
|
| Rate for Payer: Allwell Medicare |
$6.30
|
| Rate for Payer: Amerigroup Medicare |
$6.30
|
| Rate for Payer: APIPA Medicare/Medicaid |
$15.69
|
| Rate for Payer: AZCH Complete Medicare |
$6.30
|
| Rate for Payer: Banner UC Health Medicare |
$6.30
|
| Rate for Payer: Bisbee Police All Plans |
$10.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$28.56
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna of AZ Commercial |
$29.40
|
| Rate for Payer: Copperpoint Commercial |
$10.40
|
| Rate for Payer: Health Net of AZ Commercial |
$25.20
|
| Rate for Payer: Health Net of AZ Medicare |
$11.76
|
| Rate for Payer: Humana of AZ Medicare |
$6.30
|
| Rate for Payer: Self Pay Self Pay |
$33.60
|
| Rate for Payer: TriWest Medicare |
$6.30
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$24.49
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$7.56
|
|
|
INFANT NASAL PRNG 5MM TO 4MM
|
Facility
|
IP
|
$42.00
|
|
| Hospital Charge Code |
27704486
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.92 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Aetna of AZ Commercial |
$37.80
|
| Rate for Payer: Bisbee Police All Plans |
$10.92
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Self Pay Self Pay |
$33.60
|
|
|
INFANT NASAL PRNG 5MM TO 6MM
|
Facility
|
OP
|
$42.00
|
|
| Hospital Charge Code |
27704484
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Aetna of AZ Commercial |
$37.80
|
| Rate for Payer: Aetna of AZ Medicare |
$11.76
|
| Rate for Payer: Allwell Medicare |
$6.30
|
| Rate for Payer: Amerigroup Medicare |
$6.30
|
| Rate for Payer: APIPA Medicare/Medicaid |
$15.69
|
| Rate for Payer: AZCH Complete Medicare |
$6.30
|
| Rate for Payer: Banner UC Health Medicare |
$6.30
|
| Rate for Payer: Bisbee Police All Plans |
$10.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$28.56
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna of AZ Commercial |
$29.40
|
| Rate for Payer: Copperpoint Commercial |
$10.40
|
| Rate for Payer: Health Net of AZ Commercial |
$25.20
|
| Rate for Payer: Health Net of AZ Medicare |
$11.76
|
| Rate for Payer: Humana of AZ Medicare |
$6.30
|
| Rate for Payer: Self Pay Self Pay |
$33.60
|
| Rate for Payer: TriWest Medicare |
$6.30
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$24.49
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$7.56
|
|
|
INFANT NASAL PRNG 5MM TO 6MM
|
Facility
|
IP
|
$42.00
|
|
| Hospital Charge Code |
27704484
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.92 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Aetna of AZ Commercial |
$37.80
|
| Rate for Payer: Bisbee Police All Plans |
$10.92
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Self Pay Self Pay |
$33.60
|
|
|
INFANT NASAL PRNG 6MM TO 7MM
|
Facility
|
OP
|
$42.00
|
|
| Hospital Charge Code |
27704485
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Aetna of AZ Commercial |
$37.80
|
| Rate for Payer: Aetna of AZ Medicare |
$11.76
|
| Rate for Payer: Allwell Medicare |
$6.30
|
| Rate for Payer: Amerigroup Medicare |
$6.30
|
| Rate for Payer: APIPA Medicare/Medicaid |
$15.69
|
| Rate for Payer: AZCH Complete Medicare |
$6.30
|
| Rate for Payer: Banner UC Health Medicare |
$6.30
|
| Rate for Payer: Bisbee Police All Plans |
$10.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$28.56
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna of AZ Commercial |
$29.40
|
| Rate for Payer: Copperpoint Commercial |
$10.40
|
| Rate for Payer: Health Net of AZ Commercial |
$25.20
|
| Rate for Payer: Health Net of AZ Medicare |
$11.76
|
| Rate for Payer: Humana of AZ Medicare |
$6.30
|
| Rate for Payer: Self Pay Self Pay |
$33.60
|
| Rate for Payer: TriWest Medicare |
$6.30
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$24.49
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$7.56
|
|
|
INFANT NASAL PRNG 6MM TO 7MM
|
Facility
|
IP
|
$42.00
|
|
| Hospital Charge Code |
27704485
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.92 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Aetna of AZ Commercial |
$37.80
|
| Rate for Payer: Bisbee Police All Plans |
$10.92
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Self Pay Self Pay |
$33.60
|
|
|
INFANT NASAL PRONG 3MM NARE
|
Facility
|
IP
|
$42.00
|
|
| Hospital Charge Code |
27704469
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.92 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Aetna of AZ Commercial |
$37.80
|
| Rate for Payer: Bisbee Police All Plans |
$10.92
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Self Pay Self Pay |
$33.60
|
|
|
INFANT NASAL PRONG 3MM NARE
|
Facility
|
OP
|
$42.00
|
|
| Hospital Charge Code |
27704469
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Aetna of AZ Commercial |
$37.80
|
| Rate for Payer: Aetna of AZ Medicare |
$11.76
|
| Rate for Payer: Allwell Medicare |
$6.30
|
| Rate for Payer: Amerigroup Medicare |
$6.30
|
| Rate for Payer: APIPA Medicare/Medicaid |
$15.69
|
| Rate for Payer: AZCH Complete Medicare |
$6.30
|
| Rate for Payer: Banner UC Health Medicare |
$6.30
|
| Rate for Payer: Bisbee Police All Plans |
$10.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$28.56
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna of AZ Commercial |
$29.40
|
| Rate for Payer: Copperpoint Commercial |
$10.40
|
| Rate for Payer: Health Net of AZ Commercial |
$25.20
|
| Rate for Payer: Health Net of AZ Medicare |
$11.76
|
| Rate for Payer: Humana of AZ Medicare |
$6.30
|
| Rate for Payer: Self Pay Self Pay |
$33.60
|
| Rate for Payer: TriWest Medicare |
$6.30
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$24.49
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$7.56
|
|
|
Infections Of Upper Respiratory Tract
|
Facility
|
IP
|
$2,419.13
|
|
|
Service Code
|
APR-DRG 1131
|
| Hospital Charge Code |
APRDRG1134
|
| Min. Negotiated Rate |
$2,419.13 |
| Max. Negotiated Rate |
$2,419.13 |
| Rate for Payer: AHCCCS Medicaid |
$2,419.13
|
| Rate for Payer: Allwell Medicaid |
$2,419.13
|
| Rate for Payer: AZCH Complete Medicaid |
$2,419.13
|
| Rate for Payer: Banner UC Health Medicaid |
$2,419.13
|
| Rate for Payer: Mercy Care Medicaid |
$2,419.13
|
|
|
Infections Of Upper Respiratory Tract
|
Facility
|
IP
|
$9,409.98
|
|
|
Service Code
|
APR-DRG 1134
|
| Hospital Charge Code |
APRDRG1133
|
| Min. Negotiated Rate |
$9,409.98 |
| Max. Negotiated Rate |
$9,409.98 |
| Rate for Payer: AHCCCS Medicaid |
$9,409.98
|
| Rate for Payer: Allwell Medicaid |
$9,409.98
|
| Rate for Payer: AZCH Complete Medicaid |
$9,409.98
|
| Rate for Payer: Banner UC Health Medicaid |
$9,409.98
|
| Rate for Payer: Mercy Care Medicaid |
$9,409.98
|
|
|
Infections Of Upper Respiratory Tract
|
Facility
|
IP
|
$4,914.71
|
|
|
Service Code
|
APR-DRG 1133
|
| Hospital Charge Code |
APRDRG1131
|
| Min. Negotiated Rate |
$4,914.71 |
| Max. Negotiated Rate |
$4,914.71 |
| Rate for Payer: AHCCCS Medicaid |
$4,914.71
|
| Rate for Payer: Allwell Medicaid |
$4,914.71
|
| Rate for Payer: AZCH Complete Medicaid |
$4,914.71
|
| Rate for Payer: Banner UC Health Medicaid |
$4,914.71
|
| Rate for Payer: Mercy Care Medicaid |
$4,914.71
|
|
|
Infections Of Upper Respiratory Tract
|
Facility
|
IP
|
$2,419.13
|
|
|
Service Code
|
APR-DRG 1131
|
| Hospital Charge Code |
APRDRG1132
|
| Min. Negotiated Rate |
$2,419.13 |
| Max. Negotiated Rate |
$2,419.13 |
| Rate for Payer: AHCCCS Medicaid |
$2,419.13
|
| Rate for Payer: Allwell Medicaid |
$2,419.13
|
| Rate for Payer: AZCH Complete Medicaid |
$2,419.13
|
| Rate for Payer: Banner UC Health Medicaid |
$2,419.13
|
| Rate for Payer: Mercy Care Medicaid |
$2,419.13
|
|
|
Infections Of Upper Respiratory Tract
|
Facility
|
IP
|
$4,914.71
|
|
|
Service Code
|
APR-DRG 1133
|
| Hospital Charge Code |
APRDRG1134
|
| Min. Negotiated Rate |
$4,914.71 |
| Max. Negotiated Rate |
$4,914.71 |
| Rate for Payer: AHCCCS Medicaid |
$4,914.71
|
| Rate for Payer: Allwell Medicaid |
$4,914.71
|
| Rate for Payer: AZCH Complete Medicaid |
$4,914.71
|
| Rate for Payer: Banner UC Health Medicaid |
$4,914.71
|
| Rate for Payer: Mercy Care Medicaid |
$4,914.71
|
|
|
Infections Of Upper Respiratory Tract
|
Facility
|
IP
|
$3,359.71
|
|
|
Service Code
|
APR-DRG 1132
|
| Hospital Charge Code |
APRDRG1131
|
| Min. Negotiated Rate |
$3,359.71 |
| Max. Negotiated Rate |
$3,359.71 |
| Rate for Payer: AHCCCS Medicaid |
$3,359.71
|
| Rate for Payer: Allwell Medicaid |
$3,359.71
|
| Rate for Payer: AZCH Complete Medicaid |
$3,359.71
|
| Rate for Payer: Banner UC Health Medicaid |
$3,359.71
|
| Rate for Payer: Mercy Care Medicaid |
$3,359.71
|
|
|
Infections Of Upper Respiratory Tract
|
Facility
|
IP
|
$4,914.71
|
|
|
Service Code
|
APR-DRG 1133
|
| Hospital Charge Code |
APRDRG1132
|
| Min. Negotiated Rate |
$4,914.71 |
| Max. Negotiated Rate |
$4,914.71 |
| Rate for Payer: AHCCCS Medicaid |
$4,914.71
|
| Rate for Payer: Allwell Medicaid |
$4,914.71
|
| Rate for Payer: AZCH Complete Medicaid |
$4,914.71
|
| Rate for Payer: Banner UC Health Medicaid |
$4,914.71
|
| Rate for Payer: Mercy Care Medicaid |
$4,914.71
|
|
|
Infections Of Upper Respiratory Tract
|
Facility
|
IP
|
$9,409.98
|
|
|
Service Code
|
APR-DRG 1134
|
| Hospital Charge Code |
APRDRG1132
|
| Min. Negotiated Rate |
$9,409.98 |
| Max. Negotiated Rate |
$9,409.98 |
| Rate for Payer: AHCCCS Medicaid |
$9,409.98
|
| Rate for Payer: Allwell Medicaid |
$9,409.98
|
| Rate for Payer: AZCH Complete Medicaid |
$9,409.98
|
| Rate for Payer: Banner UC Health Medicaid |
$9,409.98
|
| Rate for Payer: Mercy Care Medicaid |
$9,409.98
|
|
|
Infections Of Upper Respiratory Tract
|
Facility
|
IP
|
$3,359.71
|
|
|
Service Code
|
APR-DRG 1132
|
| Hospital Charge Code |
APRDRG1133
|
| Min. Negotiated Rate |
$3,359.71 |
| Max. Negotiated Rate |
$3,359.71 |
| Rate for Payer: AHCCCS Medicaid |
$3,359.71
|
| Rate for Payer: Allwell Medicaid |
$3,359.71
|
| Rate for Payer: AZCH Complete Medicaid |
$3,359.71
|
| Rate for Payer: Banner UC Health Medicaid |
$3,359.71
|
| Rate for Payer: Mercy Care Medicaid |
$3,359.71
|
|
|
Infections Of Upper Respiratory Tract
|
Facility
|
IP
|
$3,359.71
|
|
|
Service Code
|
APR-DRG 1132
|
| Hospital Charge Code |
APRDRG1132
|
| Min. Negotiated Rate |
$3,359.71 |
| Max. Negotiated Rate |
$3,359.71 |
| Rate for Payer: AHCCCS Medicaid |
$3,359.71
|
| Rate for Payer: Allwell Medicaid |
$3,359.71
|
| Rate for Payer: AZCH Complete Medicaid |
$3,359.71
|
| Rate for Payer: Banner UC Health Medicaid |
$3,359.71
|
| Rate for Payer: Mercy Care Medicaid |
$3,359.71
|
|
|
Infections Of Upper Respiratory Tract
|
Facility
|
IP
|
$9,409.98
|
|
|
Service Code
|
APR-DRG 1134
|
| Hospital Charge Code |
APRDRG1134
|
| Min. Negotiated Rate |
$9,409.98 |
| Max. Negotiated Rate |
$9,409.98 |
| Rate for Payer: AHCCCS Medicaid |
$9,409.98
|
| Rate for Payer: Allwell Medicaid |
$9,409.98
|
| Rate for Payer: AZCH Complete Medicaid |
$9,409.98
|
| Rate for Payer: Banner UC Health Medicaid |
$9,409.98
|
| Rate for Payer: Mercy Care Medicaid |
$9,409.98
|
|
|
Infections Of Upper Respiratory Tract
|
Facility
|
IP
|
$2,419.13
|
|
|
Service Code
|
APR-DRG 1131
|
| Hospital Charge Code |
APRDRG1133
|
| Min. Negotiated Rate |
$2,419.13 |
| Max. Negotiated Rate |
$2,419.13 |
| Rate for Payer: AHCCCS Medicaid |
$2,419.13
|
| Rate for Payer: Allwell Medicaid |
$2,419.13
|
| Rate for Payer: AZCH Complete Medicaid |
$2,419.13
|
| Rate for Payer: Banner UC Health Medicaid |
$2,419.13
|
| Rate for Payer: Mercy Care Medicaid |
$2,419.13
|
|
