|
Aph RBC CP2D AS3 LR 2
|
Facility
|
OP
|
$761.00
|
|
|
Service Code
|
HCPCS P9016
|
| Hospital Charge Code |
4004201
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$120.54 |
| Max. Negotiated Rate |
$684.90 |
| Rate for Payer: Aetna of AZ Commercial |
$684.90
|
| Rate for Payer: Arizona Complete Health Allwell |
$121.76
|
| Rate for Payer: Banner UC Health Medicare |
$121.76
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$517.48
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$121.76
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$121.76
|
| Rate for Payer: Cash Price |
$608.80
|
| Rate for Payer: Cash Price |
$608.80
|
| Rate for Payer: Cigna of AZ Commercial |
$494.65
|
| Rate for Payer: Devoted Health Medicare |
$136.98
|
| Rate for Payer: Humana of AZ Medicare |
$121.76
|
| Rate for Payer: Seven Corners Travel Insurance |
$280.04
|
| Rate for Payer: Southwest Service Administrators UFCW |
$517.48
|
| Rate for Payer: TriWest Medicare |
$121.76
|
| Rate for Payer: United Healthcare Commercial |
$435.29
|
| Rate for Payer: United Healthcare Medicare |
$121.76
|
| Rate for Payer: Veterans Affairs TRICARE |
$120.54
|
|
|
apixaban 5 mg Tab UD[CQCH]
|
Facility
|
OP
|
$5.47
|
|
|
Service Code
|
NDC 3089431
|
| Hospital Charge Code |
130114009
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$4.92 |
| Rate for Payer: Aetna of AZ Commercial |
$4.92
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.88
|
| Rate for Payer: Banner UC Health Medicare |
$0.88
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.88
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.88
|
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Cigna of AZ Commercial |
$3.56
|
| Rate for Payer: Devoted Health Medicare |
$0.98
|
| Rate for Payer: Humana of AZ Medicare |
$0.88
|
| Rate for Payer: Southwest Service Administrators UFCW |
$3.72
|
| Rate for Payer: TriWest Medicare |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$3.13
|
| Rate for Payer: United Healthcare Medicare |
$0.88
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.87
|
|
|
apixaban 5 mg Tab UD[CQCH]
|
Facility
|
IP
|
$5.47
|
|
|
Service Code
|
NDC 3089431
|
| Hospital Charge Code |
130114009
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$4.92 |
| Max. Negotiated Rate |
$4.92 |
| Rate for Payer: Aetna of AZ Commercial |
$4.92
|
| Rate for Payer: Cash Price |
$4.38
|
|
|
APLIGRAF 44 SQ CM
|
Facility
|
OP
|
$3,713.00
|
|
| Hospital Charge Code |
22354189
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$588.14 |
| Max. Negotiated Rate |
$3,341.70 |
| Rate for Payer: Aetna of AZ Commercial |
$3,341.70
|
| Rate for Payer: Arizona Complete Health Allwell |
$594.08
|
| Rate for Payer: Banner UC Health Medicare |
$594.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$2,524.84
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$594.08
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$594.08
|
| Rate for Payer: Cash Price |
$2,970.40
|
| Rate for Payer: Cigna of AZ Commercial |
$2,599.10
|
| Rate for Payer: Devoted Health Medicare |
$668.34
|
| Rate for Payer: Humana of AZ Medicare |
$594.08
|
| Rate for Payer: Southwest Service Administrators UFCW |
$2,524.84
|
| Rate for Payer: TriWest Medicare |
$594.08
|
| Rate for Payer: United Healthcare Commercial |
$2,123.84
|
| Rate for Payer: United Healthcare Medicare |
$594.08
|
| Rate for Payer: Veterans Affairs TRICARE |
$588.14
|
|
|
APLIGRAF 44 SQ CM
|
Facility
|
IP
|
$3,713.00
|
|
| Hospital Charge Code |
22354189
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3,341.70 |
| Max. Negotiated Rate |
$3,341.70 |
| Rate for Payer: Aetna of AZ Commercial |
$3,341.70
|
| Rate for Payer: Cash Price |
$2,970.40
|
|
|
APLIGRAF, PER SQUARE CENTIMETER
|
Facility
|
OP
|
$164.00
|
|
|
Service Code
|
HCPCS Q4101
|
| Hospital Charge Code |
24049285
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.98 |
| Max. Negotiated Rate |
$192.55 |
| Rate for Payer: Aetna of AZ Commercial |
$147.60
|
| Rate for Payer: Arizona Complete Health Allwell |
$26.24
|
| Rate for Payer: Banner UC Health Medicare |
$26.24
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$111.52
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$26.24
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$26.24
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Cigna of AZ Commercial |
$114.80
|
| Rate for Payer: Devoted Health Medicare |
$29.52
|
| Rate for Payer: Humana of AZ Medicare |
$26.24
|
| Rate for Payer: Seven Corners Travel Insurance |
$192.55
|
| Rate for Payer: Southwest Service Administrators UFCW |
$111.52
|
| Rate for Payer: TriWest Medicare |
$26.24
|
| Rate for Payer: United Healthcare Commercial |
$93.81
|
| Rate for Payer: United Healthcare Medicare |
$26.24
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$31.16
|
| Rate for Payer: Veterans Affairs TRICARE |
$25.98
|
|
|
APLIGRAF, PER SQUARE CENTIMETER
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
HCPCS Q4101
|
| Hospital Charge Code |
24049285
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$147.60 |
| Max. Negotiated Rate |
$147.60 |
| Rate for Payer: Aetna of AZ Commercial |
$147.60
|
| Rate for Payer: Cash Price |
$131.20
|
|
|
APLIGRAPH
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
HCPCS Q4101
|
| Hospital Charge Code |
24358081
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.31 |
| Max. Negotiated Rate |
$274.50 |
| Rate for Payer: Aetna of AZ Commercial |
$274.50
|
| Rate for Payer: Arizona Complete Health Allwell |
$48.80
|
| Rate for Payer: Banner UC Health Medicare |
$48.80
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$207.40
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$48.80
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$48.80
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cigna of AZ Commercial |
$213.50
|
| Rate for Payer: Devoted Health Medicare |
$54.90
|
| Rate for Payer: Humana of AZ Medicare |
$48.80
|
| Rate for Payer: Seven Corners Travel Insurance |
$192.55
|
| Rate for Payer: Southwest Service Administrators UFCW |
$207.40
|
| Rate for Payer: TriWest Medicare |
$48.80
|
| Rate for Payer: United Healthcare Commercial |
$174.46
|
| Rate for Payer: United Healthcare Medicare |
$48.80
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$57.95
|
| Rate for Payer: Veterans Affairs TRICARE |
$48.31
|
|
|
APLIGRAPH
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
HCPCS Q4101
|
| Hospital Charge Code |
24358081
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$274.50 |
| Max. Negotiated Rate |
$274.50 |
| Rate for Payer: Aetna of AZ Commercial |
$274.50
|
| Rate for Payer: Cash Price |
$244.00
|
|
|
APOLIPOPROTEIN, EACH
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
CPT 82172
|
| Hospital Charge Code |
28010052
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$94.50 |
| Rate for Payer: Aetna of AZ Commercial |
$94.50
|
| Rate for Payer: Cash Price |
$84.00
|
|
|
APOLIPOPROTEIN, EACH
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
CPT 82172
|
| Hospital Charge Code |
28010052
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$16.63 |
| Max. Negotiated Rate |
$94.50 |
| Rate for Payer: Aetna of AZ Commercial |
$94.50
|
| Rate for Payer: Arizona Complete Health Allwell |
$16.80
|
| Rate for Payer: Banner UC Health Medicare |
$16.80
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$71.40
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$16.80
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$16.80
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna of AZ Commercial |
$68.25
|
| Rate for Payer: Devoted Health Medicare |
$18.90
|
| Rate for Payer: Humana of AZ Medicare |
$16.80
|
| Rate for Payer: Seven Corners Travel Insurance |
$30.58
|
| Rate for Payer: Southwest Service Administrators UFCW |
$71.40
|
| Rate for Payer: TriWest Medicare |
$16.80
|
| Rate for Payer: United Healthcare Commercial |
$60.06
|
| Rate for Payer: United Healthcare Medicare |
$16.80
|
| Rate for Payer: Veterans Affairs TRICARE |
$16.63
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$20,985.19
|
|
|
Service Code
|
APR-DRG 2334
|
| Hospital Charge Code |
APRDRG2334
|
| Min. Negotiated Rate |
$20,985.19 |
| Max. Negotiated Rate |
$20,985.19 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$20,985.19
|
| Rate for Payer: Mercy Care Medicaid |
$20,985.19
|
| Rate for Payer: NaphCare Correctional Healthcare |
$20,985.19
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$20,985.19
|
|
|
Service Code
|
APR-DRG 2334
|
| Hospital Charge Code |
APRDRG2332
|
| Min. Negotiated Rate |
$20,985.19 |
| Max. Negotiated Rate |
$20,985.19 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$20,985.19
|
| Rate for Payer: Mercy Care Medicaid |
$20,985.19
|
| Rate for Payer: NaphCare Correctional Healthcare |
$20,985.19
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$12,458.97
|
|
|
Service Code
|
APR-DRG 2333
|
| Hospital Charge Code |
APRDRG2333
|
| Min. Negotiated Rate |
$12,458.97 |
| Max. Negotiated Rate |
$12,458.97 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$12,458.97
|
| Rate for Payer: Mercy Care Medicaid |
$12,458.97
|
| Rate for Payer: NaphCare Correctional Healthcare |
$12,458.97
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$8,406.98
|
|
|
Service Code
|
APR-DRG 2332
|
| Hospital Charge Code |
APRDRG2332
|
| Min. Negotiated Rate |
$8,406.98 |
| Max. Negotiated Rate |
$8,406.98 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$8,406.98
|
| Rate for Payer: Mercy Care Medicaid |
$8,406.98
|
| Rate for Payer: NaphCare Correctional Healthcare |
$8,406.98
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$6,466.91
|
|
|
Service Code
|
APR-DRG 2331
|
| Hospital Charge Code |
APRDRG2333
|
| Min. Negotiated Rate |
$6,466.91 |
| Max. Negotiated Rate |
$6,466.91 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,466.91
|
| Rate for Payer: Mercy Care Medicaid |
$6,466.91
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,466.91
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$20,985.19
|
|
|
Service Code
|
APR-DRG 2334
|
| Hospital Charge Code |
APRDRG2333
|
| Min. Negotiated Rate |
$20,985.19 |
| Max. Negotiated Rate |
$20,985.19 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$20,985.19
|
| Rate for Payer: Mercy Care Medicaid |
$20,985.19
|
| Rate for Payer: NaphCare Correctional Healthcare |
$20,985.19
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$6,466.91
|
|
|
Service Code
|
APR-DRG 2331
|
| Hospital Charge Code |
APRDRG2332
|
| Min. Negotiated Rate |
$6,466.91 |
| Max. Negotiated Rate |
$6,466.91 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,466.91
|
| Rate for Payer: Mercy Care Medicaid |
$6,466.91
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,466.91
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$8,406.98
|
|
|
Service Code
|
APR-DRG 2332
|
| Hospital Charge Code |
APRDRG2333
|
| Min. Negotiated Rate |
$8,406.98 |
| Max. Negotiated Rate |
$8,406.98 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$8,406.98
|
| Rate for Payer: Mercy Care Medicaid |
$8,406.98
|
| Rate for Payer: NaphCare Correctional Healthcare |
$8,406.98
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$12,458.97
|
|
|
Service Code
|
APR-DRG 2333
|
| Hospital Charge Code |
APRDRG2331
|
| Min. Negotiated Rate |
$12,458.97 |
| Max. Negotiated Rate |
$12,458.97 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$12,458.97
|
| Rate for Payer: Mercy Care Medicaid |
$12,458.97
|
| Rate for Payer: NaphCare Correctional Healthcare |
$12,458.97
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$8,406.98
|
|
|
Service Code
|
APR-DRG 2332
|
| Hospital Charge Code |
APRDRG2331
|
| Min. Negotiated Rate |
$8,406.98 |
| Max. Negotiated Rate |
$8,406.98 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$8,406.98
|
| Rate for Payer: Mercy Care Medicaid |
$8,406.98
|
| Rate for Payer: NaphCare Correctional Healthcare |
$8,406.98
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$12,458.97
|
|
|
Service Code
|
APR-DRG 2333
|
| Hospital Charge Code |
APRDRG2332
|
| Min. Negotiated Rate |
$12,458.97 |
| Max. Negotiated Rate |
$12,458.97 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$12,458.97
|
| Rate for Payer: Mercy Care Medicaid |
$12,458.97
|
| Rate for Payer: NaphCare Correctional Healthcare |
$12,458.97
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$20,985.19
|
|
|
Service Code
|
APR-DRG 2334
|
| Hospital Charge Code |
APRDRG2331
|
| Min. Negotiated Rate |
$20,985.19 |
| Max. Negotiated Rate |
$20,985.19 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$20,985.19
|
| Rate for Payer: Mercy Care Medicaid |
$20,985.19
|
| Rate for Payer: NaphCare Correctional Healthcare |
$20,985.19
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$12,458.97
|
|
|
Service Code
|
APR-DRG 2333
|
| Hospital Charge Code |
APRDRG2334
|
| Min. Negotiated Rate |
$12,458.97 |
| Max. Negotiated Rate |
$12,458.97 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$12,458.97
|
| Rate for Payer: Mercy Care Medicaid |
$12,458.97
|
| Rate for Payer: NaphCare Correctional Healthcare |
$12,458.97
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$8,406.98
|
|
|
Service Code
|
APR-DRG 2332
|
| Hospital Charge Code |
APRDRG2334
|
| Min. Negotiated Rate |
$8,406.98 |
| Max. Negotiated Rate |
$8,406.98 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$8,406.98
|
| Rate for Payer: Mercy Care Medicaid |
$8,406.98
|
| Rate for Payer: NaphCare Correctional Healthcare |
$8,406.98
|
|
