|
influenza virus vaccine 2024-2025, inactivated preservative-free trivalent Sus UD[CQCH]
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 19515081052
|
| Hospital Charge Code |
242320050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.32 |
| Max. Negotiated Rate |
$13.32 |
| Rate for Payer: Aetna of AZ Commercial |
$13.32
|
| Rate for Payer: Cash Price |
$11.84
|
|
|
Influenza Virus Vaccine, IM, Fluzone
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
HCPCS Q2038
|
| Hospital Charge Code |
1902233
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$48.60 |
| Max. Negotiated Rate |
$48.60 |
| Rate for Payer: Aetna of AZ Commercial |
$48.60
|
| Rate for Payer: Cash Price |
$43.20
|
|
|
Influenza Virus Vaccine, IM, Fluzone
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
HCPCS Q2038
|
| Hospital Charge Code |
1902233
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$8.55 |
| Max. Negotiated Rate |
$48.60 |
| Rate for Payer: Aetna of AZ Commercial |
$48.60
|
| Rate for Payer: Arizona Complete Health Allwell |
$8.64
|
| Rate for Payer: Banner UC Health Medicare |
$8.64
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$36.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$8.64
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$8.64
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna of AZ Commercial |
$37.80
|
| Rate for Payer: Devoted Health Medicare |
$9.72
|
| Rate for Payer: Humana of AZ Medicare |
$8.64
|
| Rate for Payer: Southwest Service Administrators UFCW |
$36.72
|
| Rate for Payer: TriWest Medicare |
$8.64
|
| Rate for Payer: United Healthcare Commercial |
$30.89
|
| Rate for Payer: United Healthcare Medicare |
$8.64
|
| Rate for Payer: Veterans Affairs TRICARE |
$8.55
|
|
|
Influenza virus vaccine, live, for intranasal use
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
CPT 90660
|
| Hospital Charge Code |
4036304
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$10.61 |
| Max. Negotiated Rate |
$60.30 |
| Rate for Payer: Aetna of AZ Commercial |
$60.30
|
| Rate for Payer: Arizona Complete Health Allwell |
$10.72
|
| Rate for Payer: Banner UC Health Medicare |
$10.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$45.56
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$10.72
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$10.72
|
| Rate for Payer: Cash Price |
$53.60
|
| Rate for Payer: Cigna of AZ Commercial |
$46.90
|
| Rate for Payer: Devoted Health Medicare |
$12.06
|
| Rate for Payer: Humana of AZ Medicare |
$10.72
|
| Rate for Payer: Southwest Service Administrators UFCW |
$45.56
|
| Rate for Payer: TriWest Medicare |
$10.72
|
| Rate for Payer: United Healthcare Commercial |
$38.32
|
| Rate for Payer: United Healthcare Medicare |
$10.72
|
| Rate for Payer: Veterans Affairs TRICARE |
$10.61
|
|
|
Influenza virus vaccine, live, for intranasal use
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
CPT 90660
|
| Hospital Charge Code |
4036304
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$60.30 |
| Max. Negotiated Rate |
$60.30 |
| Rate for Payer: Aetna of AZ Commercial |
$60.30
|
| Rate for Payer: Cash Price |
$53.60
|
|
|
Influenza virus vaccine, split virus, preservative free, for children 6-35 month
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
CPT 90655
|
| Hospital Charge Code |
749825
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$47.70 |
| Rate for Payer: Aetna of AZ Commercial |
$47.70
|
| Rate for Payer: Arizona Complete Health Allwell |
$8.48
|
| Rate for Payer: Banner UC Health Medicare |
$8.48
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$36.04
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$8.48
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$8.48
|
| Rate for Payer: Cash Price |
$42.40
|
| Rate for Payer: Cigna of AZ Commercial |
$37.10
|
| Rate for Payer: Devoted Health Medicare |
$9.54
|
| Rate for Payer: Humana of AZ Medicare |
$8.48
|
| Rate for Payer: Southwest Service Administrators UFCW |
$36.04
|
| Rate for Payer: TriWest Medicare |
$8.48
|
| Rate for Payer: United Healthcare Commercial |
$30.32
|
| Rate for Payer: United Healthcare Medicare |
$8.48
|
| Rate for Payer: Veterans Affairs TRICARE |
$8.40
|
|
|
Influenza virus vaccine, split virus, preservative free, for children 6-35 month
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
CPT 90655
|
| Hospital Charge Code |
749825
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$47.70 |
| Max. Negotiated Rate |
$47.70 |
| Rate for Payer: Aetna of AZ Commercial |
$47.70
|
| Rate for Payer: Cash Price |
$42.40
|
|
|
Influenza virus vaccine, split virus, preservative free, for use in individuals
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
HCPCS T1015
|
| Hospital Charge Code |
1297239
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$8.55 |
| Max. Negotiated Rate |
$48.60 |
| Rate for Payer: Aetna of AZ Commercial |
$48.60
|
| Rate for Payer: Arizona Complete Health Allwell |
$8.64
|
| Rate for Payer: Banner UC Health Medicare |
$8.64
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$36.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$8.64
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$8.64
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna of AZ Commercial |
$37.80
|
| Rate for Payer: Devoted Health Medicare |
$9.72
|
| Rate for Payer: Humana of AZ Medicare |
$8.64
|
| Rate for Payer: Southwest Service Administrators UFCW |
$36.72
|
| Rate for Payer: TriWest Medicare |
$8.64
|
| Rate for Payer: United Healthcare Commercial |
$30.89
|
| Rate for Payer: United Healthcare Medicare |
$8.64
|
| Rate for Payer: Veterans Affairs TRICARE |
$8.55
|
|
|
Influenza virus vaccine, split virus, preservative free, for use in individuals
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
HCPCS T1015
|
| Hospital Charge Code |
1297239
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$48.60 |
| Max. Negotiated Rate |
$48.60 |
| Rate for Payer: Aetna of AZ Commercial |
$48.60
|
| Rate for Payer: Cash Price |
$43.20
|
|
|
informaSeq(SM) Prenatal Test LC
|
Facility
|
OP
|
$232.00
|
|
|
Service Code
|
CPT 81420
|
| Hospital Charge Code |
22311195
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$36.75 |
| Max. Negotiated Rate |
$1,100.62 |
| Rate for Payer: Aetna of AZ Commercial |
$208.80
|
| Rate for Payer: Arizona Complete Health Allwell |
$37.12
|
| Rate for Payer: Banner UC Health Medicare |
$37.12
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$157.76
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$37.12
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$37.12
|
| Rate for Payer: Cash Price |
$185.60
|
| Rate for Payer: Cash Price |
$185.60
|
| Rate for Payer: Cigna of AZ Commercial |
$150.80
|
| Rate for Payer: Devoted Health Medicare |
$41.76
|
| Rate for Payer: Humana of AZ Medicare |
$37.12
|
| Rate for Payer: Seven Corners Travel Insurance |
$1,100.62
|
| Rate for Payer: Southwest Service Administrators UFCW |
$157.76
|
| Rate for Payer: TriWest Medicare |
$37.12
|
| Rate for Payer: United Healthcare Commercial |
$132.70
|
| Rate for Payer: United Healthcare Medicare |
$37.12
|
| Rate for Payer: Veterans Affairs TRICARE |
$36.75
|
|
|
informaSeq(SM) Prenatal Test LC
|
Facility
|
IP
|
$232.00
|
|
|
Service Code
|
CPT 81420
|
| Hospital Charge Code |
22311195
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$208.80 |
| Max. Negotiated Rate |
$208.80 |
| Rate for Payer: Aetna of AZ Commercial |
$208.80
|
| Rate for Payer: Cash Price |
$185.60
|
|
|
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC
|
Facility
|
IP
|
$19,702.85
|
|
|
Service Code
|
MSDRG 351
|
| Min. Negotiated Rate |
$19,702.85 |
| Max. Negotiated Rate |
$19,702.85 |
| Rate for Payer: Seven Corners Travel Insurance |
$19,702.85
|
|
|
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC
|
Facility
|
IP
|
$32,205.66
|
|
|
Service Code
|
MSDRG 350
|
| Min. Negotiated Rate |
$32,205.66 |
| Max. Negotiated Rate |
$32,205.66 |
| Rate for Payer: Seven Corners Travel Insurance |
$32,205.66
|
|
|
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$15,152.85
|
|
|
Service Code
|
MSDRG 352
|
| Min. Negotiated Rate |
$15,152.85 |
| Max. Negotiated Rate |
$15,152.85 |
| Rate for Payer: Seven Corners Travel Insurance |
$15,152.85
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$5,855.99
|
|
|
Service Code
|
APR-DRG 2281
|
| Hospital Charge Code |
APRDRG2284
|
| Min. Negotiated Rate |
$5,855.99 |
| Max. Negotiated Rate |
$5,855.99 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,855.99
|
| Rate for Payer: Mercy Care Medicaid |
$5,855.99
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,855.99
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$11,253.26
|
|
|
Service Code
|
APR-DRG 2283
|
| Hospital Charge Code |
APRDRG2283
|
| Min. Negotiated Rate |
$11,253.26 |
| Max. Negotiated Rate |
$11,253.26 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$11,253.26
|
| Rate for Payer: Mercy Care Medicaid |
$11,253.26
|
| Rate for Payer: NaphCare Correctional Healthcare |
$11,253.26
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$5,855.99
|
|
|
Service Code
|
APR-DRG 2281
|
| Hospital Charge Code |
APRDRG2282
|
| Min. Negotiated Rate |
$5,855.99 |
| Max. Negotiated Rate |
$5,855.99 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,855.99
|
| Rate for Payer: Mercy Care Medicaid |
$5,855.99
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,855.99
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$7,529.53
|
|
|
Service Code
|
APR-DRG 2282
|
| Hospital Charge Code |
APRDRG2282
|
| Min. Negotiated Rate |
$7,529.53 |
| Max. Negotiated Rate |
$7,529.53 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$7,529.53
|
| Rate for Payer: Mercy Care Medicaid |
$7,529.53
|
| Rate for Payer: NaphCare Correctional Healthcare |
$7,529.53
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$11,253.26
|
|
|
Service Code
|
APR-DRG 2283
|
| Hospital Charge Code |
APRDRG2284
|
| Min. Negotiated Rate |
$11,253.26 |
| Max. Negotiated Rate |
$11,253.26 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$11,253.26
|
| Rate for Payer: Mercy Care Medicaid |
$11,253.26
|
| Rate for Payer: NaphCare Correctional Healthcare |
$11,253.26
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$7,529.53
|
|
|
Service Code
|
APR-DRG 2282
|
| Hospital Charge Code |
APRDRG2284
|
| Min. Negotiated Rate |
$7,529.53 |
| Max. Negotiated Rate |
$7,529.53 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$7,529.53
|
| Rate for Payer: Mercy Care Medicaid |
$7,529.53
|
| Rate for Payer: NaphCare Correctional Healthcare |
$7,529.53
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$5,855.99
|
|
|
Service Code
|
APR-DRG 2281
|
| Hospital Charge Code |
APRDRG2281
|
| Min. Negotiated Rate |
$5,855.99 |
| Max. Negotiated Rate |
$5,855.99 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,855.99
|
| Rate for Payer: Mercy Care Medicaid |
$5,855.99
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,855.99
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$7,529.53
|
|
|
Service Code
|
APR-DRG 2282
|
| Hospital Charge Code |
APRDRG2283
|
| Min. Negotiated Rate |
$7,529.53 |
| Max. Negotiated Rate |
$7,529.53 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$7,529.53
|
| Rate for Payer: Mercy Care Medicaid |
$7,529.53
|
| Rate for Payer: NaphCare Correctional Healthcare |
$7,529.53
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$11,253.26
|
|
|
Service Code
|
APR-DRG 2283
|
| Hospital Charge Code |
APRDRG2281
|
| Min. Negotiated Rate |
$11,253.26 |
| Max. Negotiated Rate |
$11,253.26 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$11,253.26
|
| Rate for Payer: Mercy Care Medicaid |
$11,253.26
|
| Rate for Payer: NaphCare Correctional Healthcare |
$11,253.26
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$21,389.19
|
|
|
Service Code
|
APR-DRG 2284
|
| Hospital Charge Code |
APRDRG2283
|
| Min. Negotiated Rate |
$21,389.19 |
| Max. Negotiated Rate |
$21,389.19 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$21,389.19
|
| Rate for Payer: Mercy Care Medicaid |
$21,389.19
|
| Rate for Payer: NaphCare Correctional Healthcare |
$21,389.19
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$21,389.19
|
|
|
Service Code
|
APR-DRG 2284
|
| Hospital Charge Code |
APRDRG2284
|
| Min. Negotiated Rate |
$21,389.19 |
| Max. Negotiated Rate |
$21,389.19 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$21,389.19
|
| Rate for Payer: Mercy Care Medicaid |
$21,389.19
|
| Rate for Payer: NaphCare Correctional Healthcare |
$21,389.19
|
|
