|
Hypovolemia And Related Electrolyte Disorders
|
Facility
|
IP
|
$3,302.19
|
|
|
Service Code
|
APR-DRG 4222
|
| Hospital Charge Code |
APRDRG4222
|
| Min. Negotiated Rate |
$3,302.19 |
| Max. Negotiated Rate |
$3,302.19 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,302.19
|
| Rate for Payer: Mercy Care Medicaid |
$3,302.19
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,302.19
|
|
|
Hypovolemia And Related Electrolyte Disorders
|
Facility
|
IP
|
$3,302.19
|
|
|
Service Code
|
APR-DRG 4222
|
| Hospital Charge Code |
APRDRG4223
|
| Min. Negotiated Rate |
$3,302.19 |
| Max. Negotiated Rate |
$3,302.19 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,302.19
|
| Rate for Payer: Mercy Care Medicaid |
$3,302.19
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,302.19
|
|
|
Hypovolemia And Related Electrolyte Disorders
|
Facility
|
IP
|
$5,028.34
|
|
|
Service Code
|
APR-DRG 4223
|
| Hospital Charge Code |
APRDRG4223
|
| Min. Negotiated Rate |
$5,028.34 |
| Max. Negotiated Rate |
$5,028.34 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,028.34
|
| Rate for Payer: Mercy Care Medicaid |
$5,028.34
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,028.34
|
|
|
Hypovolemia And Related Electrolyte Disorders
|
Facility
|
IP
|
$2,471.73
|
|
|
Service Code
|
APR-DRG 4221
|
| Hospital Charge Code |
APRDRG4222
|
| Min. Negotiated Rate |
$2,471.73 |
| Max. Negotiated Rate |
$2,471.73 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$2,471.73
|
| Rate for Payer: Mercy Care Medicaid |
$2,471.73
|
| Rate for Payer: NaphCare Correctional Healthcare |
$2,471.73
|
|
|
Hypovolemia And Related Electrolyte Disorders
|
Facility
|
IP
|
$10,095.25
|
|
|
Service Code
|
APR-DRG 4224
|
| Hospital Charge Code |
APRDRG4224
|
| Min. Negotiated Rate |
$10,095.25 |
| Max. Negotiated Rate |
$10,095.25 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$10,095.25
|
| Rate for Payer: Mercy Care Medicaid |
$10,095.25
|
| Rate for Payer: NaphCare Correctional Healthcare |
$10,095.25
|
|
|
Hypovolemia And Related Electrolyte Disorders
|
Facility
|
IP
|
$10,095.25
|
|
|
Service Code
|
APR-DRG 4224
|
| Hospital Charge Code |
APRDRG4222
|
| Min. Negotiated Rate |
$10,095.25 |
| Max. Negotiated Rate |
$10,095.25 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$10,095.25
|
| Rate for Payer: Mercy Care Medicaid |
$10,095.25
|
| Rate for Payer: NaphCare Correctional Healthcare |
$10,095.25
|
|
|
Hypovolemia And Related Electrolyte Disorders
|
Facility
|
IP
|
$5,028.34
|
|
|
Service Code
|
APR-DRG 4223
|
| Hospital Charge Code |
APRDRG4222
|
| Min. Negotiated Rate |
$5,028.34 |
| Max. Negotiated Rate |
$5,028.34 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,028.34
|
| Rate for Payer: Mercy Care Medicaid |
$5,028.34
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,028.34
|
|
|
Hypovolemia And Related Electrolyte Disorders
|
Facility
|
IP
|
$2,471.73
|
|
|
Service Code
|
APR-DRG 4221
|
| Hospital Charge Code |
APRDRG4221
|
| Min. Negotiated Rate |
$2,471.73 |
| Max. Negotiated Rate |
$2,471.73 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$2,471.73
|
| Rate for Payer: Mercy Care Medicaid |
$2,471.73
|
| Rate for Payer: NaphCare Correctional Healthcare |
$2,471.73
|
|
|
Hypovolemia And Related Electrolyte Disorders
|
Facility
|
IP
|
$2,471.73
|
|
|
Service Code
|
APR-DRG 4221
|
| Hospital Charge Code |
APRDRG4223
|
| Min. Negotiated Rate |
$2,471.73 |
| Max. Negotiated Rate |
$2,471.73 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$2,471.73
|
| Rate for Payer: Mercy Care Medicaid |
$2,471.73
|
| Rate for Payer: NaphCare Correctional Healthcare |
$2,471.73
|
|
|
Hypovolemia And Related Electrolyte Disorders
|
Facility
|
IP
|
$10,095.25
|
|
|
Service Code
|
APR-DRG 4224
|
| Hospital Charge Code |
APRDRG4221
|
| Min. Negotiated Rate |
$10,095.25 |
| Max. Negotiated Rate |
$10,095.25 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$10,095.25
|
| Rate for Payer: Mercy Care Medicaid |
$10,095.25
|
| Rate for Payer: NaphCare Correctional Healthcare |
$10,095.25
|
|
|
Hypovolemia And Related Electrolyte Disorders
|
Facility
|
IP
|
$10,095.25
|
|
|
Service Code
|
APR-DRG 4224
|
| Hospital Charge Code |
APRDRG4223
|
| Min. Negotiated Rate |
$10,095.25 |
| Max. Negotiated Rate |
$10,095.25 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$10,095.25
|
| Rate for Payer: Mercy Care Medicaid |
$10,095.25
|
| Rate for Payer: NaphCare Correctional Healthcare |
$10,095.25
|
|
|
Hypovolemia And Related Electrolyte Disorders
|
Facility
|
IP
|
$2,471.73
|
|
|
Service Code
|
APR-DRG 4221
|
| Hospital Charge Code |
APRDRG4224
|
| Min. Negotiated Rate |
$2,471.73 |
| Max. Negotiated Rate |
$2,471.73 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$2,471.73
|
| Rate for Payer: Mercy Care Medicaid |
$2,471.73
|
| Rate for Payer: NaphCare Correctional Healthcare |
$2,471.73
|
|
|
Hypovolemia And Related Electrolyte Disorders
|
Facility
|
IP
|
$5,028.34
|
|
|
Service Code
|
APR-DRG 4223
|
| Hospital Charge Code |
APRDRG4221
|
| Min. Negotiated Rate |
$5,028.34 |
| Max. Negotiated Rate |
$5,028.34 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,028.34
|
| Rate for Payer: Mercy Care Medicaid |
$5,028.34
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,028.34
|
|
|
Hypovolemia And Related Electrolyte Disorders
|
Facility
|
IP
|
$3,302.19
|
|
|
Service Code
|
APR-DRG 4222
|
| Hospital Charge Code |
APRDRG4221
|
| Min. Negotiated Rate |
$3,302.19 |
| Max. Negotiated Rate |
$3,302.19 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,302.19
|
| Rate for Payer: Mercy Care Medicaid |
$3,302.19
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,302.19
|
|
|
Hysteroscopy diagnostic
|
Facility
|
OP
|
$824.00
|
|
|
Service Code
|
CPT 58555
|
| Hospital Charge Code |
27267836
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$130.52 |
| Max. Negotiated Rate |
$5,008.71 |
| Rate for Payer: Aetna of AZ Commercial |
$741.60
|
| Rate for Payer: Arizona Complete Health Allwell |
$131.84
|
| Rate for Payer: Banner UC Health Medicare |
$1,051.19
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$560.32
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$190.37
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$131.84
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$131.84
|
| Rate for Payer: Cash Price |
$659.20
|
| Rate for Payer: Cash Price |
$659.20
|
| Rate for Payer: Cash Price |
$659.20
|
| Rate for Payer: Cigna of AZ Commercial |
$412.00
|
| Rate for Payer: Devoted Health Medicare |
$148.32
|
| Rate for Payer: Humana of AZ Medicare |
$131.84
|
| Rate for Payer: Mercy Care Medicaid |
$190.37
|
| Rate for Payer: NaphCare Correctional Healthcare |
$1,051.19
|
| Rate for Payer: Seven Corners Travel Insurance |
$5,008.71
|
| Rate for Payer: Southwest Service Administrators UFCW |
$560.32
|
| Rate for Payer: TriWest Medicare |
$131.84
|
| Rate for Payer: United Healthcare Commercial |
$4,169.00
|
| Rate for Payer: United Healthcare Medicare |
$131.84
|
| Rate for Payer: Veterans Affairs TRICARE |
$130.52
|
|
|
Hysteroscopy diagnostic
|
Facility
|
IP
|
$824.00
|
|
|
Service Code
|
CPT 58555
|
| Hospital Charge Code |
27267836
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$741.60 |
| Max. Negotiated Rate |
$741.60 |
| Rate for Payer: Aetna of AZ Commercial |
$741.60
|
| Rate for Payer: Cash Price |
$659.20
|
|
|
Hysteroscopy, surgical; with removal of leiomyomata
|
Facility
|
OP
|
$7,740.14
|
|
|
Service Code
|
CPT 58561
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,698.98 |
| Max. Negotiated Rate |
$7,740.14 |
| Rate for Payer: Banner UC Health Medicare |
$1,698.98
|
| Rate for Payer: NaphCare Correctional Healthcare |
$1,698.98
|
| Rate for Payer: Seven Corners Travel Insurance |
$7,740.14
|
| Rate for Payer: United Healthcare Commercial |
$4,838.00
|
|
|
HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIU
|
Facility
|
IP
|
$1,247.00
|
|
|
Service Code
|
CPT 58558
|
| Hospital Charge Code |
22892680
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,122.30 |
| Max. Negotiated Rate |
$1,122.30 |
| Rate for Payer: Aetna of AZ Commercial |
$1,122.30
|
| Rate for Payer: Cash Price |
$997.60
|
|
|
HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIU
|
Facility
|
OP
|
$1,247.00
|
|
|
Service Code
|
CPT 58558
|
| Hospital Charge Code |
22892680
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$197.52 |
| Max. Negotiated Rate |
$5,008.71 |
| Rate for Payer: Aetna of AZ Commercial |
$1,122.30
|
| Rate for Payer: Arizona Complete Health Allwell |
$199.52
|
| Rate for Payer: Banner UC Health Medicare |
$199.52
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$847.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$1,033.11
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$199.52
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$199.52
|
| Rate for Payer: Cash Price |
$997.60
|
| Rate for Payer: Cash Price |
$997.60
|
| Rate for Payer: Cigna of AZ Commercial |
$872.90
|
| Rate for Payer: Devoted Health Medicare |
$224.46
|
| Rate for Payer: Humana of AZ Medicare |
$199.52
|
| Rate for Payer: Mercy Care Medicaid |
$1,033.11
|
| Rate for Payer: NaphCare Correctional Healthcare |
$1,033.11
|
| Rate for Payer: Seven Corners Travel Insurance |
$5,008.71
|
| Rate for Payer: Southwest Service Administrators UFCW |
$847.96
|
| Rate for Payer: TriWest Medicare |
$199.52
|
| Rate for Payer: United Healthcare Commercial |
$713.28
|
| Rate for Payer: United Healthcare Medicare |
$199.52
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$236.93
|
| Rate for Payer: Veterans Affairs TRICARE |
$197.52
|
|
|
Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C
|
Facility
|
OP
|
$5,008.71
|
|
|
Service Code
|
CPT 58558
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,033.11 |
| Max. Negotiated Rate |
$5,008.71 |
| Rate for Payer: Banner UC Health Medicare |
$1,051.19
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$1,033.11
|
| Rate for Payer: Mercy Care Medicaid |
$1,033.11
|
| Rate for Payer: NaphCare Correctional Healthcare |
$1,051.19
|
| Rate for Payer: Seven Corners Travel Insurance |
$5,008.71
|
| Rate for Payer: United Healthcare Commercial |
$4,169.00
|
|
|
Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C
|
Facility
|
OP
|
$5,008.71
|
|
|
Service Code
|
CPT 58558
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$1,033.11 |
| Max. Negotiated Rate |
$5,008.71 |
| Rate for Payer: Banner UC Health Medicare |
$1,051.19
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$1,033.11
|
| Rate for Payer: Mercy Care Medicaid |
$1,033.11
|
| Rate for Payer: NaphCare Correctional Healthcare |
$1,051.19
|
| Rate for Payer: Seven Corners Travel Insurance |
$5,008.71
|
| Rate for Payer: United Healthcare Commercial |
$4,169.00
|
|
|
ibuprofen 100 mg/5 mL Oral Susp [CQCH]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 50383058407
|
| Hospital Charge Code |
105926316
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of AZ Commercial |
$0.11
|
| 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 |
$0.08
|
| 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 |
$0.08
|
| Rate for Payer: Devoted Health Medicare |
$0.02
|
| Rate for Payer: Humana of AZ Medicare |
$0.02
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.08
|
| Rate for Payer: TriWest Medicare |
$0.02
|
| Rate for Payer: United Healthcare Commercial |
$0.07
|
| Rate for Payer: United Healthcare Medicare |
$0.02
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.02
|
|
|
ibuprofen 100 mg/5 mL Oral Susp [CQCH]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 50383058407
|
| Hospital Charge Code |
105926316
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of AZ Commercial |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
|
|
ibuprofen 400 mg Tab [CQCH]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 63739067210
|
| Hospital Charge Code |
105926513
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of AZ Commercial |
$0.05
|
| 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 |
$0.03
|
| 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 |
$0.04
|
| Rate for Payer: Cigna of AZ Commercial |
$0.03
|
| Rate for Payer: Devoted Health Medicare |
$0.01
|
| Rate for Payer: Humana of AZ Medicare |
$0.01
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.03
|
| Rate for Payer: TriWest Medicare |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
| Rate for Payer: United Healthcare Medicare |
$0.01
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.01
|
|
|
ibuprofen 400 mg Tab [CQCH]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 63739067210
|
| Hospital Charge Code |
105926513
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of AZ Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
|
