|
ketorolac 30 mg Inj Sol [CQCH]
|
Facility
|
OP
|
$0.88
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
105927498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Aetna of AZ Commercial |
$0.79
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.14
|
| Rate for Payer: Banner UC Health Medicare |
$0.14
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.14
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.14
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of AZ Commercial |
$0.57
|
| Rate for Payer: Devoted Health Medicare |
$0.16
|
| Rate for Payer: Humana of AZ Medicare |
$0.14
|
| Rate for Payer: Seven Corners Travel Insurance |
$0.44
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.60
|
| Rate for Payer: TriWest Medicare |
$0.14
|
| Rate for Payer: United Healthcare Commercial |
$0.50
|
| Rate for Payer: United Healthcare Medicare |
$0.14
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.14
|
|
|
ketorolac 60 mg Inj Sol [CQCH]
|
Facility
|
OP
|
$0.91
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
105927571
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of AZ Commercial |
$0.82
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.15
|
| Rate for Payer: Banner UC Health Medicare |
$0.15
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.62
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.15
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.15
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna of AZ Commercial |
$0.59
|
| Rate for Payer: Devoted Health Medicare |
$0.16
|
| Rate for Payer: Humana of AZ Medicare |
$0.15
|
| Rate for Payer: Seven Corners Travel Insurance |
$0.44
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.62
|
| Rate for Payer: TriWest Medicare |
$0.15
|
| Rate for Payer: United Healthcare Commercial |
$0.52
|
| Rate for Payer: United Healthcare Medicare |
$0.15
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.14
|
|
|
ketorolac 60 mg Inj Sol [CQCH]
|
Facility
|
IP
|
$0.91
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
105927571
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of AZ Commercial |
$0.82
|
| Rate for Payer: Cash Price |
$0.73
|
|
|
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC
|
Facility
|
IP
|
$23,651.17
|
|
|
Service Code
|
MSDRG 657
|
| Min. Negotiated Rate |
$23,651.17 |
| Max. Negotiated Rate |
$23,651.17 |
| Rate for Payer: Seven Corners Travel Insurance |
$23,651.17
|
|
|
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC
|
Facility
|
IP
|
$41,147.88
|
|
|
Service Code
|
MSDRG 656
|
| Min. Negotiated Rate |
$41,147.88 |
| Max. Negotiated Rate |
$41,147.88 |
| Rate for Payer: Seven Corners Travel Insurance |
$41,147.88
|
|
|
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC
|
Facility
|
IP
|
$20,055.67
|
|
|
Service Code
|
MSDRG 658
|
| Min. Negotiated Rate |
$20,055.67 |
| Max. Negotiated Rate |
$20,055.67 |
| Rate for Payer: Seven Corners Travel Insurance |
$20,055.67
|
|
|
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC
|
Facility
|
IP
|
$17,102.95
|
|
|
Service Code
|
MSDRG 660
|
| Min. Negotiated Rate |
$17,102.95 |
| Max. Negotiated Rate |
$17,102.95 |
| Rate for Payer: Seven Corners Travel Insurance |
$17,102.95
|
|
|
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC
|
Facility
|
IP
|
$32,838.92
|
|
|
Service Code
|
MSDRG 659
|
| Min. Negotiated Rate |
$32,838.92 |
| Max. Negotiated Rate |
$32,838.92 |
| Rate for Payer: Seven Corners Travel Insurance |
$32,838.92
|
|
|
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC
|
Facility
|
IP
|
$13,475.18
|
|
|
Service Code
|
MSDRG 661
|
| Min. Negotiated Rate |
$13,475.18 |
| Max. Negotiated Rate |
$13,475.18 |
| Rate for Payer: Seven Corners Travel Insurance |
$13,475.18
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$9,414.89
|
|
|
Service Code
|
APR-DRG 4634
|
| Hospital Charge Code |
APRDRG4631
|
| Min. Negotiated Rate |
$9,414.89 |
| Max. Negotiated Rate |
$9,414.89 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$9,414.89
|
| Rate for Payer: Mercy Care Medicaid |
$9,414.89
|
| Rate for Payer: NaphCare Correctional Healthcare |
$9,414.89
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$5,325.73
|
|
|
Service Code
|
APR-DRG 4633
|
| Hospital Charge Code |
APRDRG4631
|
| Min. Negotiated Rate |
$5,325.73 |
| Max. Negotiated Rate |
$5,325.73 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,325.73
|
| Rate for Payer: Mercy Care Medicaid |
$5,325.73
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,325.73
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$3,173.84
|
|
|
Service Code
|
APR-DRG 4631
|
| Hospital Charge Code |
APRDRG4634
|
| Min. Negotiated Rate |
$3,173.84 |
| Max. Negotiated Rate |
$3,173.84 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,173.84
|
| Rate for Payer: Mercy Care Medicaid |
$3,173.84
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,173.84
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$9,414.89
|
|
|
Service Code
|
APR-DRG 4634
|
| Hospital Charge Code |
APRDRG4632
|
| Min. Negotiated Rate |
$9,414.89 |
| Max. Negotiated Rate |
$9,414.89 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$9,414.89
|
| Rate for Payer: Mercy Care Medicaid |
$9,414.89
|
| Rate for Payer: NaphCare Correctional Healthcare |
$9,414.89
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$9,414.89
|
|
|
Service Code
|
APR-DRG 4634
|
| Hospital Charge Code |
APRDRG4633
|
| Min. Negotiated Rate |
$9,414.89 |
| Max. Negotiated Rate |
$9,414.89 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$9,414.89
|
| Rate for Payer: Mercy Care Medicaid |
$9,414.89
|
| Rate for Payer: NaphCare Correctional Healthcare |
$9,414.89
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$3,173.84
|
|
|
Service Code
|
APR-DRG 4631
|
| Hospital Charge Code |
APRDRG4632
|
| Min. Negotiated Rate |
$3,173.84 |
| Max. Negotiated Rate |
$3,173.84 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,173.84
|
| Rate for Payer: Mercy Care Medicaid |
$3,173.84
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,173.84
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$5,325.73
|
|
|
Service Code
|
APR-DRG 4633
|
| Hospital Charge Code |
APRDRG4634
|
| Min. Negotiated Rate |
$5,325.73 |
| Max. Negotiated Rate |
$5,325.73 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,325.73
|
| Rate for Payer: Mercy Care Medicaid |
$5,325.73
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,325.73
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$3,863.31
|
|
|
Service Code
|
APR-DRG 4632
|
| Hospital Charge Code |
APRDRG4634
|
| Min. Negotiated Rate |
$3,863.31 |
| Max. Negotiated Rate |
$3,863.31 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,863.31
|
| Rate for Payer: Mercy Care Medicaid |
$3,863.31
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,863.31
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$9,414.89
|
|
|
Service Code
|
APR-DRG 4634
|
| Hospital Charge Code |
APRDRG4634
|
| Min. Negotiated Rate |
$9,414.89 |
| Max. Negotiated Rate |
$9,414.89 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$9,414.89
|
| Rate for Payer: Mercy Care Medicaid |
$9,414.89
|
| Rate for Payer: NaphCare Correctional Healthcare |
$9,414.89
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$5,325.73
|
|
|
Service Code
|
APR-DRG 4633
|
| Hospital Charge Code |
APRDRG4632
|
| Min. Negotiated Rate |
$5,325.73 |
| Max. Negotiated Rate |
$5,325.73 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,325.73
|
| Rate for Payer: Mercy Care Medicaid |
$5,325.73
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,325.73
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$3,173.84
|
|
|
Service Code
|
APR-DRG 4631
|
| Hospital Charge Code |
APRDRG4631
|
| Min. Negotiated Rate |
$3,173.84 |
| Max. Negotiated Rate |
$3,173.84 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,173.84
|
| Rate for Payer: Mercy Care Medicaid |
$3,173.84
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,173.84
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$5,325.73
|
|
|
Service Code
|
APR-DRG 4633
|
| Hospital Charge Code |
APRDRG4633
|
| Min. Negotiated Rate |
$5,325.73 |
| Max. Negotiated Rate |
$5,325.73 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,325.73
|
| Rate for Payer: Mercy Care Medicaid |
$5,325.73
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,325.73
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$3,173.84
|
|
|
Service Code
|
APR-DRG 4631
|
| Hospital Charge Code |
APRDRG4633
|
| Min. Negotiated Rate |
$3,173.84 |
| Max. Negotiated Rate |
$3,173.84 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,173.84
|
| Rate for Payer: Mercy Care Medicaid |
$3,173.84
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,173.84
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$3,863.31
|
|
|
Service Code
|
APR-DRG 4632
|
| Hospital Charge Code |
APRDRG4633
|
| Min. Negotiated Rate |
$3,863.31 |
| Max. Negotiated Rate |
$3,863.31 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,863.31
|
| Rate for Payer: Mercy Care Medicaid |
$3,863.31
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,863.31
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$3,863.31
|
|
|
Service Code
|
APR-DRG 4632
|
| Hospital Charge Code |
APRDRG4631
|
| Min. Negotiated Rate |
$3,863.31 |
| Max. Negotiated Rate |
$3,863.31 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,863.31
|
| Rate for Payer: Mercy Care Medicaid |
$3,863.31
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,863.31
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$3,863.31
|
|
|
Service Code
|
APR-DRG 4632
|
| Hospital Charge Code |
APRDRG4632
|
| Min. Negotiated Rate |
$3,863.31 |
| Max. Negotiated Rate |
$3,863.31 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,863.31
|
| Rate for Payer: Mercy Care Medicaid |
$3,863.31
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,863.31
|
|
