|
FERNOTRAC TRACTION SPLINT ADULT
|
Facility
|
IP
|
$1,546.00
|
|
| Hospital Charge Code |
24335304
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,391.40 |
| Max. Negotiated Rate |
$1,391.40 |
| Rate for Payer: Aetna of AZ Commercial |
$1,391.40
|
| Rate for Payer: Cash Price |
$1,236.80
|
|
|
Fern Test
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
CPT 89060
|
| Hospital Charge Code |
853209
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$103.50 |
| Max. Negotiated Rate |
$103.50 |
| Rate for Payer: Aetna of AZ Commercial |
$103.50
|
| Rate for Payer: Cash Price |
$92.00
|
|
|
Fern Test
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
CPT 89060
|
| Hospital Charge Code |
853209
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$10.63 |
| Max. Negotiated Rate |
$103.50 |
| Rate for Payer: Aetna of AZ Commercial |
$103.50
|
| Rate for Payer: Arizona Complete Health Allwell |
$18.40
|
| Rate for Payer: Banner UC Health Medicare |
$18.40
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$78.20
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$18.40
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$18.40
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cigna of AZ Commercial |
$74.75
|
| Rate for Payer: Devoted Health Medicare |
$20.70
|
| Rate for Payer: Humana of AZ Medicare |
$18.40
|
| Rate for Payer: Seven Corners Travel Insurance |
$10.63
|
| Rate for Payer: Southwest Service Administrators UFCW |
$78.20
|
| Rate for Payer: TriWest Medicare |
$18.40
|
| Rate for Payer: United Healthcare Commercial |
$65.78
|
| Rate for Payer: United Healthcare Medicare |
$18.40
|
| Rate for Payer: Veterans Affairs TRICARE |
$18.22
|
|
|
ferric carboxymaltose (as elemental iron) 50 mg/mL Sol[CQCH]
|
Facility
|
OP
|
$57.54
|
|
|
Service Code
|
HCPCS J1439
|
| Hospital Charge Code |
193172985
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$51.79 |
| Rate for Payer: Aetna of AZ Commercial |
$51.79
|
| Rate for Payer: Arizona Complete Health Allwell |
$9.21
|
| Rate for Payer: Banner UC Health Medicare |
$9.21
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$39.13
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$9.21
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$9.21
|
| Rate for Payer: Cash Price |
$46.03
|
| Rate for Payer: Cash Price |
$46.03
|
| Rate for Payer: Cigna of AZ Commercial |
$37.40
|
| Rate for Payer: Devoted Health Medicare |
$10.36
|
| Rate for Payer: Humana of AZ Medicare |
$9.21
|
| Rate for Payer: Seven Corners Travel Insurance |
$1.64
|
| Rate for Payer: Southwest Service Administrators UFCW |
$39.13
|
| Rate for Payer: TriWest Medicare |
$9.21
|
| Rate for Payer: United Healthcare Commercial |
$32.91
|
| Rate for Payer: United Healthcare Medicare |
$9.21
|
| Rate for Payer: Veterans Affairs TRICARE |
$9.11
|
|
|
ferric carboxymaltose (as elemental iron) 50 mg/mL Sol[CQCH]
|
Facility
|
IP
|
$57.54
|
|
|
Service Code
|
HCPCS J1439
|
| Hospital Charge Code |
193172985
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.79 |
| Max. Negotiated Rate |
$51.79 |
| Rate for Payer: Aetna of AZ Commercial |
$51.79
|
| Rate for Payer: Cash Price |
$46.03
|
|
|
Ferritin
|
Facility
|
OP
|
$241.00
|
|
|
Service Code
|
CPT 82728
|
| Hospital Charge Code |
633726
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.76 |
| Max. Negotiated Rate |
$216.90 |
| Rate for Payer: Aetna of AZ Commercial |
$216.90
|
| Rate for Payer: Aetna of AZ Commercial |
$161.10
|
| Rate for Payer: Arizona Complete Health Allwell |
$28.64
|
| Rate for Payer: Arizona Complete Health Allwell |
$38.56
|
| Rate for Payer: Banner UC Health Medicare |
$28.64
|
| Rate for Payer: Banner UC Health Medicare |
$38.56
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$163.88
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$121.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$28.64
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$38.56
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$28.64
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$38.56
|
| Rate for Payer: Cash Price |
$192.80
|
| Rate for Payer: Cash Price |
$143.20
|
| Rate for Payer: Cash Price |
$192.80
|
| Rate for Payer: Cash Price |
$143.20
|
| Rate for Payer: Cigna of AZ Commercial |
$156.65
|
| Rate for Payer: Cigna of AZ Commercial |
$116.35
|
| Rate for Payer: Devoted Health Medicare |
$43.38
|
| Rate for Payer: Devoted Health Medicare |
$32.22
|
| Rate for Payer: Humana of AZ Medicare |
$28.64
|
| Rate for Payer: Humana of AZ Medicare |
$38.56
|
| Rate for Payer: Seven Corners Travel Insurance |
$19.76
|
| Rate for Payer: Seven Corners Travel Insurance |
$19.76
|
| Rate for Payer: Southwest Service Administrators UFCW |
$121.72
|
| Rate for Payer: Southwest Service Administrators UFCW |
$163.88
|
| Rate for Payer: TriWest Medicare |
$28.64
|
| Rate for Payer: TriWest Medicare |
$38.56
|
| Rate for Payer: United Healthcare Commercial |
$137.85
|
| Rate for Payer: United Healthcare Commercial |
$102.39
|
| Rate for Payer: United Healthcare Medicare |
$28.64
|
| Rate for Payer: United Healthcare Medicare |
$38.56
|
| Rate for Payer: Veterans Affairs TRICARE |
$38.17
|
| Rate for Payer: Veterans Affairs TRICARE |
$28.35
|
|
|
Ferritin
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
CPT 82728
|
| Hospital Charge Code |
633726
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$161.10 |
| Max. Negotiated Rate |
$161.10 |
| Rate for Payer: Aetna of AZ Commercial |
$161.10
|
| Rate for Payer: Aetna of AZ Commercial |
$216.90
|
| Rate for Payer: Cash Price |
$143.20
|
| Rate for Payer: Cash Price |
$192.80
|
|
|
ferrous gluconate 324 mg Tab [CQCH]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 574050811
|
| Hospital Charge Code |
105922585
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of AZ Commercial |
$0.08
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.01
|
| Rate for Payer: Banner UC Health Medicare |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.01
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.01
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of AZ Commercial |
$0.06
|
| Rate for Payer: Devoted Health Medicare |
$0.02
|
| Rate for Payer: Humana of AZ Medicare |
$0.01
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.06
|
| Rate for Payer: TriWest Medicare |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.05
|
| Rate for Payer: United Healthcare Medicare |
$0.01
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.01
|
|
|
ferrous gluconate 324 mg Tab [CQCH]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 574050811
|
| Hospital Charge Code |
105922585
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of AZ Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
|
|
ferrous sulfate 300 mg/5 mL Oral Liq UD [CQCH]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 121053005
|
| Hospital Charge Code |
105922715
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of AZ Commercial |
$0.16
|
| 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 |
$0.12
|
| 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 |
$0.14
|
| 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 |
$0.12
|
| Rate for Payer: TriWest Medicare |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.10
|
| Rate for Payer: United Healthcare Medicare |
$0.03
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.03
|
|
|
ferrous sulfate 300 mg/5 mL Oral Liq UD [CQCH]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 121053005
|
| Hospital Charge Code |
105922715
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of AZ Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
|
|
ferrous sulfate 325 mg Tab [CQCH]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 904759161
|
| Hospital Charge Code |
105922650
|
|
Hospital Revenue Code
|
251
|
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of AZ Commercial |
$0.03
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.00
|
| Rate for Payer: Banner UC Health Medicare |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.00
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.00
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of AZ Commercial |
$0.02
|
| Rate for Payer: Devoted Health Medicare |
$0.01
|
| Rate for Payer: Humana of AZ Medicare |
$0.00
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.02
|
| Rate for Payer: TriWest Medicare |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.02
|
| Rate for Payer: United Healthcare Medicare |
$0.00
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.00
|
|
|
ferrous sulfate 325 mg Tab [CQCH]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 904759161
|
| Hospital Charge Code |
105922650
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of AZ Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
|
|
ferumoxytol 30 mg/mL Sol[CQCH]
|
Facility
|
IP
|
$14.79
|
|
|
Service Code
|
HCPCS Q0138
|
| Hospital Charge Code |
199592805
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.31 |
| Max. Negotiated Rate |
$13.31 |
| Rate for Payer: Aetna of AZ Commercial |
$13.31
|
| Rate for Payer: Cash Price |
$11.83
|
|
|
ferumoxytol 30 mg/mL Sol[CQCH]
|
Facility
|
OP
|
$14.79
|
|
|
Service Code
|
HCPCS Q0138
|
| Hospital Charge Code |
199592805
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$13.31 |
| Rate for Payer: Aetna of AZ Commercial |
$13.31
|
| Rate for Payer: Arizona Complete Health Allwell |
$2.37
|
| Rate for Payer: Banner UC Health Medicare |
$2.37
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$10.06
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$2.37
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$2.37
|
| Rate for Payer: Cash Price |
$11.83
|
| Rate for Payer: Cash Price |
$11.83
|
| Rate for Payer: Cigna of AZ Commercial |
$9.61
|
| Rate for Payer: Devoted Health Medicare |
$2.66
|
| Rate for Payer: Humana of AZ Medicare |
$2.37
|
| Rate for Payer: Seven Corners Travel Insurance |
$0.54
|
| Rate for Payer: Southwest Service Administrators UFCW |
$10.06
|
| Rate for Payer: TriWest Medicare |
$2.37
|
| Rate for Payer: United Healthcare Commercial |
$8.46
|
| Rate for Payer: United Healthcare Medicare |
$2.37
|
| Rate for Payer: Veterans Affairs TRICARE |
$2.34
|
|
|
Fever And Inflammatory Conditions
|
Facility
|
IP
|
$5,346.07
|
|
|
Service Code
|
APR-DRG 7223
|
| Hospital Charge Code |
APRDRG7223
|
| Min. Negotiated Rate |
$5,346.07 |
| Max. Negotiated Rate |
$5,346.07 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,346.07
|
| Rate for Payer: Mercy Care Medicaid |
$5,346.07
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,346.07
|
|
|
Fever And Inflammatory Conditions
|
Facility
|
IP
|
$3,953.09
|
|
|
Service Code
|
APR-DRG 7222
|
| Hospital Charge Code |
APRDRG7223
|
| Min. Negotiated Rate |
$3,953.09 |
| Max. Negotiated Rate |
$3,953.09 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,953.09
|
| Rate for Payer: Mercy Care Medicaid |
$3,953.09
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,953.09
|
|
|
Fever And Inflammatory Conditions
|
Facility
|
IP
|
$2,771.93
|
|
|
Service Code
|
APR-DRG 7221
|
| Hospital Charge Code |
APRDRG7223
|
| Min. Negotiated Rate |
$2,771.93 |
| Max. Negotiated Rate |
$2,771.93 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$2,771.93
|
| Rate for Payer: Mercy Care Medicaid |
$2,771.93
|
| Rate for Payer: NaphCare Correctional Healthcare |
$2,771.93
|
|
|
Fever And Inflammatory Conditions
|
Facility
|
IP
|
$8,982.13
|
|
|
Service Code
|
APR-DRG 7224
|
| Hospital Charge Code |
APRDRG7221
|
| Min. Negotiated Rate |
$8,982.13 |
| Max. Negotiated Rate |
$8,982.13 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$8,982.13
|
| Rate for Payer: Mercy Care Medicaid |
$8,982.13
|
| Rate for Payer: NaphCare Correctional Healthcare |
$8,982.13
|
|
|
Fever And Inflammatory Conditions
|
Facility
|
IP
|
$5,346.07
|
|
|
Service Code
|
APR-DRG 7223
|
| Hospital Charge Code |
APRDRG7221
|
| Min. Negotiated Rate |
$5,346.07 |
| Max. Negotiated Rate |
$5,346.07 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,346.07
|
| Rate for Payer: Mercy Care Medicaid |
$5,346.07
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,346.07
|
|
|
Fever And Inflammatory Conditions
|
Facility
|
IP
|
$3,953.09
|
|
|
Service Code
|
APR-DRG 7222
|
| Hospital Charge Code |
APRDRG7221
|
| Min. Negotiated Rate |
$3,953.09 |
| Max. Negotiated Rate |
$3,953.09 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,953.09
|
| Rate for Payer: Mercy Care Medicaid |
$3,953.09
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,953.09
|
|
|
Fever And Inflammatory Conditions
|
Facility
|
IP
|
$2,771.93
|
|
|
Service Code
|
APR-DRG 7221
|
| Hospital Charge Code |
APRDRG7221
|
| Min. Negotiated Rate |
$2,771.93 |
| Max. Negotiated Rate |
$2,771.93 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$2,771.93
|
| Rate for Payer: Mercy Care Medicaid |
$2,771.93
|
| Rate for Payer: NaphCare Correctional Healthcare |
$2,771.93
|
|
|
Fever And Inflammatory Conditions
|
Facility
|
IP
|
$2,771.93
|
|
|
Service Code
|
APR-DRG 7221
|
| Hospital Charge Code |
APRDRG7222
|
| Min. Negotiated Rate |
$2,771.93 |
| Max. Negotiated Rate |
$2,771.93 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$2,771.93
|
| Rate for Payer: Mercy Care Medicaid |
$2,771.93
|
| Rate for Payer: NaphCare Correctional Healthcare |
$2,771.93
|
|
|
Fever And Inflammatory Conditions
|
Facility
|
IP
|
$5,346.07
|
|
|
Service Code
|
APR-DRG 7223
|
| Hospital Charge Code |
APRDRG7224
|
| Min. Negotiated Rate |
$5,346.07 |
| Max. Negotiated Rate |
$5,346.07 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,346.07
|
| Rate for Payer: Mercy Care Medicaid |
$5,346.07
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,346.07
|
|
|
Fever And Inflammatory Conditions
|
Facility
|
IP
|
$8,982.13
|
|
|
Service Code
|
APR-DRG 7224
|
| Hospital Charge Code |
APRDRG7222
|
| Min. Negotiated Rate |
$8,982.13 |
| Max. Negotiated Rate |
$8,982.13 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$8,982.13
|
| Rate for Payer: Mercy Care Medicaid |
$8,982.13
|
| Rate for Payer: NaphCare Correctional Healthcare |
$8,982.13
|
|
