|
Signs, Symptoms And Other Factors Influencing Health Status
|
Facility
|
IP
|
$5,985.05
|
|
|
Service Code
|
APR-DRG 8613
|
| Hospital Charge Code |
APRDRG8612
|
| Min. Negotiated Rate |
$5,985.05 |
| Max. Negotiated Rate |
$5,985.05 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,985.05
|
| Rate for Payer: Mercy Care Medicaid |
$5,985.05
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,985.05
|
|
|
Signs, Symptoms And Other Factors Influencing Health Status
|
Facility
|
IP
|
$5,985.05
|
|
|
Service Code
|
APR-DRG 8613
|
| Hospital Charge Code |
APRDRG8613
|
| Min. Negotiated Rate |
$5,985.05 |
| Max. Negotiated Rate |
$5,985.05 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,985.05
|
| Rate for Payer: Mercy Care Medicaid |
$5,985.05
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,985.05
|
|
|
Signs, Symptoms And Other Factors Influencing Health Status
|
Facility
|
IP
|
$5,985.05
|
|
|
Service Code
|
APR-DRG 8613
|
| Hospital Charge Code |
APRDRG8614
|
| Min. Negotiated Rate |
$5,985.05 |
| Max. Negotiated Rate |
$5,985.05 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,985.05
|
| Rate for Payer: Mercy Care Medicaid |
$5,985.05
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,985.05
|
|
|
Signs, Symptoms And Other Factors Influencing Health Status
|
Facility
|
IP
|
$9,865.19
|
|
|
Service Code
|
APR-DRG 8614
|
| Hospital Charge Code |
APRDRG8614
|
| Min. Negotiated Rate |
$9,865.19 |
| Max. Negotiated Rate |
$9,865.19 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$9,865.19
|
| Rate for Payer: Mercy Care Medicaid |
$9,865.19
|
| Rate for Payer: NaphCare Correctional Healthcare |
$9,865.19
|
|
|
Signs, Symptoms And Other Factors Influencing Health Status
|
Facility
|
IP
|
$9,865.19
|
|
|
Service Code
|
APR-DRG 8614
|
| Hospital Charge Code |
APRDRG8613
|
| Min. Negotiated Rate |
$9,865.19 |
| Max. Negotiated Rate |
$9,865.19 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$9,865.19
|
| Rate for Payer: Mercy Care Medicaid |
$9,865.19
|
| Rate for Payer: NaphCare Correctional Healthcare |
$9,865.19
|
|
|
Signs, Symptoms And Other Factors Influencing Health Status
|
Facility
|
IP
|
$3,340.07
|
|
|
Service Code
|
APR-DRG 8611
|
| Hospital Charge Code |
APRDRG8614
|
| Min. Negotiated Rate |
$3,340.07 |
| Max. Negotiated Rate |
$3,340.07 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,340.07
|
| Rate for Payer: Mercy Care Medicaid |
$3,340.07
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,340.07
|
|
|
Signs, Symptoms And Other Factors Influencing Health Status
|
Facility
|
IP
|
$4,167.02
|
|
|
Service Code
|
APR-DRG 8612
|
| Hospital Charge Code |
APRDRG8613
|
| Min. Negotiated Rate |
$4,167.02 |
| Max. Negotiated Rate |
$4,167.02 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,167.02
|
| Rate for Payer: Mercy Care Medicaid |
$4,167.02
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,167.02
|
|
|
Signs, Symptoms And Other Factors Influencing Health Status
|
Facility
|
IP
|
$3,340.07
|
|
|
Service Code
|
APR-DRG 8611
|
| Hospital Charge Code |
APRDRG8613
|
| Min. Negotiated Rate |
$3,340.07 |
| Max. Negotiated Rate |
$3,340.07 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,340.07
|
| Rate for Payer: Mercy Care Medicaid |
$3,340.07
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,340.07
|
|
|
Signs, Symptoms And Other Factors Influencing Health Status
|
Facility
|
IP
|
$9,865.19
|
|
|
Service Code
|
APR-DRG 8614
|
| Hospital Charge Code |
APRDRG8612
|
| Min. Negotiated Rate |
$9,865.19 |
| Max. Negotiated Rate |
$9,865.19 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$9,865.19
|
| Rate for Payer: Mercy Care Medicaid |
$9,865.19
|
| Rate for Payer: NaphCare Correctional Healthcare |
$9,865.19
|
|
|
Signs, Symptoms And Other Factors Influencing Health Status
|
Facility
|
IP
|
$3,340.07
|
|
|
Service Code
|
APR-DRG 8611
|
| Hospital Charge Code |
APRDRG8611
|
| Min. Negotiated Rate |
$3,340.07 |
| Max. Negotiated Rate |
$3,340.07 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,340.07
|
| Rate for Payer: Mercy Care Medicaid |
$3,340.07
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,340.07
|
|
|
Signs, Symptoms And Other Factors Influencing Health Status
|
Facility
|
IP
|
$5,985.05
|
|
|
Service Code
|
APR-DRG 8613
|
| Hospital Charge Code |
APRDRG8611
|
| Min. Negotiated Rate |
$5,985.05 |
| Max. Negotiated Rate |
$5,985.05 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,985.05
|
| Rate for Payer: Mercy Care Medicaid |
$5,985.05
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,985.05
|
|
|
Signs, Symptoms And Other Factors Influencing Health Status
|
Facility
|
IP
|
$4,167.02
|
|
|
Service Code
|
APR-DRG 8612
|
| Hospital Charge Code |
APRDRG8614
|
| Min. Negotiated Rate |
$4,167.02 |
| Max. Negotiated Rate |
$4,167.02 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,167.02
|
| Rate for Payer: Mercy Care Medicaid |
$4,167.02
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,167.02
|
|
|
Signs, Symptoms And Other Factors Influencing Health Status
|
Facility
|
IP
|
$4,167.02
|
|
|
Service Code
|
APR-DRG 8612
|
| Hospital Charge Code |
APRDRG8611
|
| Min. Negotiated Rate |
$4,167.02 |
| Max. Negotiated Rate |
$4,167.02 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,167.02
|
| Rate for Payer: Mercy Care Medicaid |
$4,167.02
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,167.02
|
|
|
Signs, Symptoms And Other Factors Influencing Health Status
|
Facility
|
IP
|
$3,340.07
|
|
|
Service Code
|
APR-DRG 8611
|
| Hospital Charge Code |
APRDRG8612
|
| Min. Negotiated Rate |
$3,340.07 |
| Max. Negotiated Rate |
$3,340.07 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,340.07
|
| Rate for Payer: Mercy Care Medicaid |
$3,340.07
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,340.07
|
|
|
SILICONE EPISTAXIS BALLOON
|
Facility
|
OP
|
$290.00
|
|
| Hospital Charge Code |
27526363
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$45.94 |
| Max. Negotiated Rate |
$261.00 |
| Rate for Payer: Aetna of AZ Commercial |
$261.00
|
| Rate for Payer: Arizona Complete Health Allwell |
$46.40
|
| Rate for Payer: Banner UC Health Medicare |
$46.40
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$197.20
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$46.40
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$46.40
|
| Rate for Payer: Cash Price |
$232.00
|
| Rate for Payer: Cigna of AZ Commercial |
$203.00
|
| Rate for Payer: Devoted Health Medicare |
$52.20
|
| Rate for Payer: Humana of AZ Medicare |
$46.40
|
| Rate for Payer: Southwest Service Administrators UFCW |
$197.20
|
| Rate for Payer: TriWest Medicare |
$46.40
|
| Rate for Payer: United Healthcare Commercial |
$165.88
|
| Rate for Payer: United Healthcare Medicare |
$46.40
|
| Rate for Payer: Veterans Affairs TRICARE |
$45.94
|
|
|
SILICONE EPISTAXIS BALLOON
|
Facility
|
IP
|
$290.00
|
|
| Hospital Charge Code |
27526363
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$261.00 |
| Max. Negotiated Rate |
$261.00 |
| Rate for Payer: Aetna of AZ Commercial |
$261.00
|
| Rate for Payer: Cash Price |
$232.00
|
|
|
silver nitrate Top Stick [CQCH]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 12870000102
|
| Hospital Charge Code |
105940241
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of AZ Commercial |
$0.32
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.06
|
| Rate for Payer: Banner UC Health Medicare |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.24
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.06
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of AZ Commercial |
$0.23
|
| Rate for Payer: Devoted Health Medicare |
$0.06
|
| Rate for Payer: Humana of AZ Medicare |
$0.06
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.24
|
| Rate for Payer: TriWest Medicare |
$0.06
|
| Rate for Payer: United Healthcare Commercial |
$0.21
|
| Rate for Payer: United Healthcare Medicare |
$0.06
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.06
|
|
|
silver nitrate Top Stick [CQCH]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 12870000102
|
| Hospital Charge Code |
105940241
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of AZ Commercial |
$0.32
|
| Rate for Payer: Cash Price |
$0.29
|
|
|
silver sulfADIAZINE Top 1% Crm 25 Gm [CQCH]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 43598021025
|
| Hospital Charge Code |
105940345
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of AZ Commercial |
$0.23
|
| 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 |
$0.18
|
| 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 |
$0.21
|
| Rate for Payer: Cigna of AZ Commercial |
$0.17
|
| Rate for Payer: Devoted Health Medicare |
$0.05
|
| Rate for Payer: Humana of AZ Medicare |
$0.04
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.18
|
| Rate for Payer: TriWest Medicare |
$0.04
|
| Rate for Payer: United Healthcare Commercial |
$0.15
|
| Rate for Payer: United Healthcare Medicare |
$0.04
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.04
|
|
|
silver sulfADIAZINE Top 1% Crm 25 Gm [CQCH]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 43598021025
|
| Hospital Charge Code |
105940345
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of AZ Commercial |
$0.23
|
| Rate for Payer: Cash Price |
$0.21
|
|
|
silver sulfADIAZINE Top 1% Crm 400Gm [CQCH]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 61570013140
|
| Hospital Charge Code |
105940410
|
|
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
|
|
|
silver sulfADIAZINE Top 1% Crm 400Gm [CQCH]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 61570013140
|
| Hospital Charge Code |
105940410
|
|
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
|
|
|
simethicone 20 mg/0.3 mL Oral Liq [CQCH]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 603089450
|
| Hospital Charge Code |
105940540
|
|
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
|
|
|
simethicone 20 mg/0.3 mL Oral Liq [CQCH]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 603089450
|
| Hospital Charge Code |
105940540
|
|
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
|
|
|
simethicone 80 mg Chew Tab [CQCH]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 904506860
|
| Hospital Charge Code |
105940475
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of AZ Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
|
