|
LOOP EXCISION ELECTRODE 15MMX10MM CONMED
|
Facility
|
IP
|
$109.00
|
|
| Hospital Charge Code |
22554977
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$98.10 |
| Max. Negotiated Rate |
$98.10 |
| Rate for Payer: Aetna of AZ Commercial |
$98.10
|
| Rate for Payer: Cash Price |
$87.20
|
|
|
LOOP EXCISION ELECTRODE 15MMX10MM CONMED
|
Facility
|
OP
|
$109.00
|
|
| Hospital Charge Code |
22554977
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$98.10 |
| Rate for Payer: Aetna of AZ Commercial |
$98.10
|
| Rate for Payer: Arizona Complete Health Allwell |
$17.44
|
| Rate for Payer: Banner UC Health Medicare |
$17.44
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$74.12
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$17.44
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$17.44
|
| Rate for Payer: Cash Price |
$87.20
|
| Rate for Payer: Cigna of AZ Commercial |
$76.30
|
| Rate for Payer: Devoted Health Medicare |
$19.62
|
| Rate for Payer: Humana of AZ Medicare |
$17.44
|
| Rate for Payer: Southwest Service Administrators UFCW |
$74.12
|
| Rate for Payer: TriWest Medicare |
$17.44
|
| Rate for Payer: United Healthcare Commercial |
$62.35
|
| Rate for Payer: United Healthcare Medicare |
$17.44
|
| Rate for Payer: Veterans Affairs TRICARE |
$17.27
|
|
|
LOOP EXCISION ELECTRODE 20MMX10MM CONMED
|
Facility
|
OP
|
$109.00
|
|
| Hospital Charge Code |
22554976
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$98.10 |
| Rate for Payer: Aetna of AZ Commercial |
$98.10
|
| Rate for Payer: Arizona Complete Health Allwell |
$17.44
|
| Rate for Payer: Banner UC Health Medicare |
$17.44
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$74.12
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$17.44
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$17.44
|
| Rate for Payer: Cash Price |
$87.20
|
| Rate for Payer: Cigna of AZ Commercial |
$76.30
|
| Rate for Payer: Devoted Health Medicare |
$19.62
|
| Rate for Payer: Humana of AZ Medicare |
$17.44
|
| Rate for Payer: Southwest Service Administrators UFCW |
$74.12
|
| Rate for Payer: TriWest Medicare |
$17.44
|
| Rate for Payer: United Healthcare Commercial |
$62.35
|
| Rate for Payer: United Healthcare Medicare |
$17.44
|
| Rate for Payer: Veterans Affairs TRICARE |
$17.27
|
|
|
LOOP EXCISION ELECTRODE 20MMX10MM CONMED
|
Facility
|
IP
|
$109.00
|
|
| Hospital Charge Code |
22554976
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$98.10 |
| Max. Negotiated Rate |
$98.10 |
| Rate for Payer: Aetna of AZ Commercial |
$98.10
|
| Rate for Payer: Cash Price |
$87.20
|
|
|
loperamide 2 mg Cap [CQCH]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
NDC 60687022901
|
| Hospital Charge Code |
105929610
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Aetna of AZ Commercial |
$0.55
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.10
|
| Rate for Payer: Banner UC Health Medicare |
$0.10
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.41
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.10
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of AZ Commercial |
$0.40
|
| Rate for Payer: Devoted Health Medicare |
$0.11
|
| Rate for Payer: Humana of AZ Medicare |
$0.10
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.41
|
| Rate for Payer: TriWest Medicare |
$0.10
|
| Rate for Payer: United Healthcare Commercial |
$0.35
|
| Rate for Payer: United Healthcare Medicare |
$0.10
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.10
|
|
|
loperamide 2 mg Cap [CQCH]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
NDC 60687022901
|
| Hospital Charge Code |
105929610
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Aetna of AZ Commercial |
$0.55
|
| Rate for Payer: Cash Price |
$0.49
|
|
|
loratadine 10 mg Tab [CQCH]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 904685261
|
| Hospital Charge Code |
105929675
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of AZ Commercial |
$0.21
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.04
|
| Rate for Payer: Banner UC Health Medicare |
$0.04
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.04
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.04
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of AZ Commercial |
$0.15
|
| Rate for Payer: Devoted Health Medicare |
$0.04
|
| Rate for Payer: Humana of AZ Medicare |
$0.04
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.16
|
| Rate for Payer: TriWest Medicare |
$0.04
|
| Rate for Payer: United Healthcare Commercial |
$0.13
|
| Rate for Payer: United Healthcare Medicare |
$0.04
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.04
|
|
|
loratadine 10 mg Tab [CQCH]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 904685261
|
| Hospital Charge Code |
105929675
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of AZ Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
|
|
LORazepam 0.5 mg Tab [CQCH]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 904600761
|
| Hospital Charge Code |
105929878
|
|
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
|
|
|
LORazepam 0.5 mg Tab [CQCH]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 904600761
|
| Hospital Charge Code |
105929878
|
|
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
|
|
|
LORazepam 1 mg Tab [CQCH]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 904600861
|
| Hospital Charge Code |
105929811
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of AZ Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
|
|
LORazepam 1 mg Tab [CQCH]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 904600861
|
| Hospital Charge Code |
105929811
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of AZ Commercial |
$0.06
|
| 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 |
$0.05
|
| 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 |
$0.05
|
| Rate for Payer: Cigna of AZ Commercial |
$0.05
|
| Rate for Payer: Devoted Health Medicare |
$0.01
|
| Rate for Payer: Humana of AZ Medicare |
$0.01
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.05
|
| Rate for Payer: TriWest Medicare |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.04
|
| Rate for Payer: United Healthcare Medicare |
$0.01
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.01
|
|
|
LORazepam 2 mg/mL Sol[CQCH]
|
Facility
|
OP
|
$0.52
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
121468467
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of AZ Commercial |
$0.47
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.08
|
| Rate for Payer: Banner UC Health Medicare |
$0.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.35
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.08
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of AZ Commercial |
$0.34
|
| Rate for Payer: Devoted Health Medicare |
$0.09
|
| Rate for Payer: Humana of AZ Medicare |
$0.08
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.35
|
| Rate for Payer: TriWest Medicare |
$0.08
|
| Rate for Payer: United Healthcare Commercial |
$0.30
|
| Rate for Payer: United Healthcare Medicare |
$0.08
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.08
|
|
|
LORazepam 2 mg/mL Sol[CQCH]
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
121468467
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of AZ Commercial |
$0.47
|
| Rate for Payer: Cash Price |
$0.42
|
|
|
losartan 50 mg Tab [CQCH]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 904704861
|
| Hospital Charge Code |
105929945
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Aetna of AZ Commercial |
$0.28
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.05
|
| Rate for Payer: Banner UC Health Medicare |
$0.05
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.21
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.05
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of AZ Commercial |
$0.20
|
| Rate for Payer: Devoted Health Medicare |
$0.06
|
| Rate for Payer: Humana of AZ Medicare |
$0.05
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.21
|
| Rate for Payer: TriWest Medicare |
$0.05
|
| Rate for Payer: United Healthcare Commercial |
$0.18
|
| Rate for Payer: United Healthcare Medicare |
$0.05
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.05
|
|
|
losartan 50 mg Tab [CQCH]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 904704861
|
| Hospital Charge Code |
105929945
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Aetna of AZ Commercial |
$0.28
|
| Rate for Payer: Cash Price |
$0.25
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC
|
Facility
|
IP
|
$32,776.89
|
|
|
Service Code
|
MSDRG 493
|
| Min. Negotiated Rate |
$32,776.89 |
| Max. Negotiated Rate |
$32,776.89 |
| Rate for Payer: Seven Corners Travel Insurance |
$32,776.89
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC
|
Facility
|
IP
|
$47,452.28
|
|
|
Service Code
|
MSDRG 492
|
| Min. Negotiated Rate |
$47,452.28 |
| Max. Negotiated Rate |
$47,452.28 |
| Rate for Payer: Seven Corners Travel Insurance |
$47,452.28
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC
|
Facility
|
IP
|
$25,932.31
|
|
|
Service Code
|
MSDRG 494
|
| Min. Negotiated Rate |
$25,932.31 |
| Max. Negotiated Rate |
$25,932.31 |
| Rate for Payer: Seven Corners Travel Insurance |
$25,932.31
|
|
|
Lower Extremity Arterial Procedures
|
Facility
|
IP
|
$9,384.03
|
|
|
Service Code
|
APR-DRG 1811
|
| Hospital Charge Code |
APRDRG1811
|
| Min. Negotiated Rate |
$9,384.03 |
| Max. Negotiated Rate |
$9,384.03 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$9,384.03
|
| Rate for Payer: Mercy Care Medicaid |
$9,384.03
|
| Rate for Payer: NaphCare Correctional Healthcare |
$9,384.03
|
|
|
Lower Extremity Arterial Procedures
|
Facility
|
IP
|
$13,613.47
|
|
|
Service Code
|
APR-DRG 1812
|
| Hospital Charge Code |
APRDRG1814
|
| Min. Negotiated Rate |
$13,613.47 |
| Max. Negotiated Rate |
$13,613.47 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$13,613.47
|
| Rate for Payer: Mercy Care Medicaid |
$13,613.47
|
| Rate for Payer: NaphCare Correctional Healthcare |
$13,613.47
|
|
|
Lower Extremity Arterial Procedures
|
Facility
|
IP
|
$37,239.43
|
|
|
Service Code
|
APR-DRG 1814
|
| Hospital Charge Code |
APRDRG1812
|
| Min. Negotiated Rate |
$37,239.43 |
| Max. Negotiated Rate |
$37,239.43 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$37,239.43
|
| Rate for Payer: Mercy Care Medicaid |
$37,239.43
|
| Rate for Payer: NaphCare Correctional Healthcare |
$37,239.43
|
|
|
Lower Extremity Arterial Procedures
|
Facility
|
IP
|
$22,058.33
|
|
|
Service Code
|
APR-DRG 1813
|
| Hospital Charge Code |
APRDRG1812
|
| Min. Negotiated Rate |
$22,058.33 |
| Max. Negotiated Rate |
$22,058.33 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$22,058.33
|
| Rate for Payer: Mercy Care Medicaid |
$22,058.33
|
| Rate for Payer: NaphCare Correctional Healthcare |
$22,058.33
|
|
|
Lower Extremity Arterial Procedures
|
Facility
|
IP
|
$22,058.33
|
|
|
Service Code
|
APR-DRG 1813
|
| Hospital Charge Code |
APRDRG1813
|
| Min. Negotiated Rate |
$22,058.33 |
| Max. Negotiated Rate |
$22,058.33 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$22,058.33
|
| Rate for Payer: Mercy Care Medicaid |
$22,058.33
|
| Rate for Payer: NaphCare Correctional Healthcare |
$22,058.33
|
|
|
Lower Extremity Arterial Procedures
|
Facility
|
IP
|
$9,384.03
|
|
|
Service Code
|
APR-DRG 1811
|
| Hospital Charge Code |
APRDRG1813
|
| Min. Negotiated Rate |
$9,384.03 |
| Max. Negotiated Rate |
$9,384.03 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$9,384.03
|
| Rate for Payer: Mercy Care Medicaid |
$9,384.03
|
| Rate for Payer: NaphCare Correctional Healthcare |
$9,384.03
|
|
